Provider Demographics
NPI:1508945452
Name:JOHNSON TAYLOR, LISA L (MA, LP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:JOHNSON TAYLOR
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 SOUTHCROSS DR W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7012
Mailing Address - Country:US
Mailing Address - Phone:952-892-7690
Mailing Address - Fax:952-898-4930
Practice Address - Street 1:1751 SOUTHCROSS DR W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7012
Practice Address - Country:US
Practice Address - Phone:952-892-7690
Practice Address - Fax:952-898-4930
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3787103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist