Healthcare Provider Details

I. General information

NPI: 1700093663
Provider Name (Legal Business Name): NICHOLAS ANDERS JOHNSON MT-BC, NMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 LASALLE AVE
MINNEAPOLIS MN
55403-2027
US

IV. Provider business mailing address

705 SMITH AVE S
SAINT PAUL MN
55107-2623
US

V. Phone/Fax

Practice location:
  • Phone: 612-321-0100
  • Fax:
Mailing address:
  • Phone: 651-797-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: