Healthcare Provider Details

I. General information

NPI: 1427715838
Provider Name (Legal Business Name): MAXINE JOHNSON MA. LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 10/28/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GLENWOOD AVE
MINNEAPOLIS MN
55405-1430
US

IV. Provider business mailing address

8641 QUEEN AVE S
BLOOMINGTON MN
55431-1903
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: