Healthcare Provider Details

I. General information

NPI: 1639168446
Provider Name (Legal Business Name): CYNTHIA LYNNE JOHNSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SMITH AVE N, MAIL ROUTE 60222
ST. PAUL MN
55102
US

IV. Provider business mailing address

333 SMITH AVE N, MAIL ROUTE 60222
ST. PAUL MN
55102
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-8565
  • Fax: 651-241-7168
Mailing address:
  • Phone: 651-241-8565
  • Fax: 651-241-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3230
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: