Provider Demographics
NPI:1912409129
Name:JOHNSON, ERIC MICHAEL
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 41ST PL NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-3068
Mailing Address - Country:US
Mailing Address - Phone:763-443-8482
Mailing Address - Fax:
Practice Address - Street 1:9766 FALLON AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4589
Practice Address - Country:US
Practice Address - Phone:763-732-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-03
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health