Healthcare Provider Details

I. General information

NPI: 1053614131
Provider Name (Legal Business Name): CALM-CLINIC FOR ATTENTION, LEARNING, AND MEMOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 WILLOW ST SUITE 600
MINNEAPOLIS MN
55403-2269
US

IV. Provider business mailing address

1409 WILLOW ST #600
MINNEAPOLIS MN
55403
US

V. Phone/Fax

Practice location:
  • Phone: 612-872-9072
  • Fax: 612-872-8605
Mailing address:
  • Phone: 612-872-2343
  • Fax: 612-872-4279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP1794
License Number StateMN

VIII. Authorized Official

Name: DR. GARY GENE JOHNSON
Title or Position: OWNER & PRESIDENT
Credential: PHD
Phone: 612-419-3266