Provider Demographics
NPI:1982063657
Name:JOHNSON, TIFFANY IRENE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
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 1:5905 GOLDEN VALLEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4455
Mailing Address - Country:US
Mailing Address - Phone:763-225-4052
Mailing Address - Fax:888-965-5130
Practice Address - Street 1:5905 GOLDEN VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4455
Practice Address - Country:US
Practice Address - Phone:763-225-4052
Practice Address - Fax:888-965-5130
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN210051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical