MEDICARE: DR. GARY GENE JOHNSON PH.D, LP, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP1794	MN

General Provider Information

NPI Number	:	1245452291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY GENE JOHNSON PH.D, LP, LMFT

Provider Business Mailing Address
First Line	:	430 OAK GROVE STREET
Second Line	:	SUITE 414
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3242
Country	:	US
Telephone Number	:	612-872-9072
Fax Number	:	612-872-8605

Provider Business Practice Location Address
First Line	:	430 OAK GROVE STREET
Second Line	:	SUITE 414
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3242
Country	:	US
Telephone Number	:	612-872-9072
Fax Number	:	612-872-8605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/09/2007

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