Provider Demographics
NPI:1811301252
Name:JOHNSON, CYNTHIA IRENE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:IRENE
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 1:7015 258TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8305
Mailing Address - Country:US
Mailing Address - Phone:651-491-1311
Mailing Address - Fax:
Practice Address - Street 1:7015 258TH ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8305
Practice Address - Country:US
Practice Address - Phone:651-491-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN203991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical