Healthcare Provider Details

I. General information

NPI: 1659281988
Provider Name (Legal Business Name): INITIATIVE PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 SUMMIT AVE
SAINT PAUL MN
55102-2624
US

IV. Provider business mailing address

PO BOX 8008
SAINT PAUL MN
55108-0008
US

V. Phone/Fax

Practice location:
  • Phone: 507-327-7309
  • Fax:
Mailing address:
  • Phone: 507-327-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MEAGHAN JOHANSEN
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D., LP
Phone: 507-327-7309