Healthcare Provider Details

I. General information

NPI: 1154310126
Provider Name (Legal Business Name): TIM JOHNSON M.S.W., LICSW & LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8669 EAGLE POINT BLVD
LAKE ELMO MN
55042-8628
US

IV. Provider business mailing address

8669 EAGLE POINT BLVD
LAKE ELMO MN
55042-8628
US

V. Phone/Fax

Practice location:
  • Phone: 651-379-0444
  • Fax: 651-379-0448
Mailing address:
  • Phone: 651-379-0444
  • Fax: 651-379-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number409
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number157
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: