Healthcare Provider Details

I. General information

NPI: 1912307257
Provider Name (Legal Business Name): ADRIENNE RENAE JOHNSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OLEARY LN
EAGAN MN
55123-2340
US

IV. Provider business mailing address

3450 OLEARY LN
EAGAN MN
55123-2340
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-0114
  • Fax: 651-454-3492
Mailing address:
  • Phone: 651-454-0114
  • Fax: 651-454-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21216
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: