Provider Demographics
NPI:1649893587
Name:NICOLE M. JOHNSON, PSYD, LP, LLC
Entity type:Organization
Organization Name:NICOLE M. JOHNSON, PSYD, LP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE M. JOHNSON
Authorized Official - Middle Name:PSYD
Authorized Official - Last Name:LP
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:612-249-0287
Mailing Address - Street 1:200 E TRAVELERS TRL STE 205
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4191
Mailing Address - Country:US
Mailing Address - Phone:612-249-0269
Mailing Address - Fax:612-249-8540
Practice Address - Street 1:200 E TRAVELERS TRL STE 205
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4191
Practice Address - Country:US
Practice Address - Phone:612-249-0269
Practice Address - Fax:612-249-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1649893587OtherNPI II