Provider Demographics
NPI:1700898970
Name:JOHNSON, MARCIE C (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARCIE
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 COMO AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1737
Mailing Address - Country:US
Mailing Address - Phone:651-646-8985
Mailing Address - Fax:651-646-3959
Practice Address - Street 1:2265 COMO AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1737
Practice Address - Country:US
Practice Address - Phone:651-646-8985
Practice Address - Fax:651-646-3959
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN075461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
01012588OtherPREFERRED ONE
42G11JOOtherBLUE CROSS/BLUE SHIELD