Provider Demographics
NPI:1831584580
Name:JOHNSON, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 SHINGLE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2322
Mailing Address - Country:US
Mailing Address - Phone:763-569-5200
Mailing Address - Fax:763-569-5201
Practice Address - Street 1:5910 SHINGLE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2322
Practice Address - Country:US
Practice Address - Phone:763-569-5200
Practice Address - Fax:763-569-5201
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4006106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist