Healthcare Provider Details

I. General information

NPI: 1497637730
Provider Name (Legal Business Name): ROSE JOHNSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 MAIN ST N UNIT 315
STILLWATER MN
55082-5026
US

IV. Provider business mailing address

432 4TH ST N
BAYPORT MN
55003-1110
US

V. Phone/Fax

Practice location:
  • Phone: 612-840-4701
  • Fax:
Mailing address:
  • Phone: 612-840-4701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC04648
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: