Provider Demographics
NPI:1740678291
Name:JOHNSON, KATIE (MA, LPCC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 TWELVE OAKS CENTER DR STE 208
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4420
Mailing Address - Country:US
Mailing Address - Phone:612-324-8702
Mailing Address - Fax:952-209-1511
Practice Address - Street 1:700 TWELVE OAKS CENTER DR STE 208
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4420
Practice Address - Country:US
Practice Address - Phone:612-324-8702
Practice Address - Fax:952-209-1511
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01929101YP2500X
MN01595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1740678291Medicaid