MEDICARE: PATRICK DOYLE JOHNSON LGSW

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	133V00000X	Registered Dietitian	4046	MN
2	101YM0800X	Mental Health Counselor	31334	MN

General Provider Information

NPI Number	:	1720700784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK DOYLE JOHNSON LGSW

Provider Business Mailing Address
First Line	:	2912 N 2ND ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2912 N 2ND ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1606
Country	:	US
Telephone Number	:	952-258-3989
Fax Number	:

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

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	09/16/2022

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