Provider Demographics
NPI:1669766366
Name:JOHNSON, KAREN (CCDC III)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 S MINNESOTA AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4746
Mailing Address - Country:US
Mailing Address - Phone:605-334-1822
Mailing Address - Fax:605-334-1823
Practice Address - Street 1:2701 S MINNESOTA AVE STE 6
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4746
Practice Address - Country:US
Practice Address - Phone:605-334-1822
Practice Address - Fax:605-334-1823
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9803978101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5000430Medicaid