Provider Demographics
NPI:1811901093
Name:JOHNSON, DONNA (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 COBB RD
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8121
Mailing Address - Country:US
Mailing Address - Phone:612-803-3737
Mailing Address - Fax:
Practice Address - Street 1:1919 UNIVERSITY AVE W STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3435
Practice Address - Country:US
Practice Address - Phone:651-266-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41Q23JOOtherBCBS
MN122753OtherUC
MN292827200Medicaid
MN1016381OtherP1
MN134814OtherCP
MN26291OtherHP
FM61-53007OtherUBH
MN122753OtherUC