Provider Demographics
NPI:1669251062
Name:JOHNSON, WESLEY (LLC)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:SABIN
Mailing Address - State:MN
Mailing Address - Zip Code:56580-4006
Mailing Address - Country:US
Mailing Address - Phone:810-730-7473
Mailing Address - Fax:
Practice Address - Street 1:16 3RD ST N
Practice Address - Street 2:
Practice Address - City:SABIN
Practice Address - State:MN
Practice Address - Zip Code:56580-4006
Practice Address - Country:US
Practice Address - Phone:810-730-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health