Provider Demographics
NPI:1881127272
Name:JOHNSON, BROOKE (LADC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7811
Mailing Address - Country:US
Mailing Address - Phone:952-484-7100
Mailing Address - Fax:
Practice Address - Street 1:69 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1004
Practice Address - Country:US
Practice Address - Phone:651-232-4284
Practice Address - Fax:651-326-3900
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304552101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20-0898277Medicaid