Provider Demographics
NPI:1457969057
Name:JOHNSON, MADELINE BAKER (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:BAKER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3659 MAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1133
Mailing Address - Country:US
Mailing Address - Phone:847-525-8852
Mailing Address - Fax:
Practice Address - Street 1:21000 ROGERS DR STE 200
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4926
Practice Address - Country:US
Practice Address - Phone:763-291-5505
Practice Address - Fax:763-657-0819
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health