Provider Demographics
NPI:1295733319
Name:JOHNSON, IRENE TERESA (MSW, LCSW, LICSW)
Entity type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:TERESA
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MSW, LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ELM STREET N FARGO VA HCS
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:307-745-8915
Mailing Address - Fax:
Practice Address - Street 1:2102 ELM STREET N FARGO VA HCS
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:307-745-8761
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-3741041C0700X
WY3741041C0700X
MN278551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
800012487OtherRR MED
WY311123OtherBS
WYW308684Medicare PIN