Healthcare Provider Details

I. General information

NPI: 1619803517
Provider Name (Legal Business Name): GRACE ANN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 FORDEM AVE
MADISON WI
53704-4696
US

IV. Provider business mailing address

2120 FORDEM AVE
MADISON WI
53704-4696
US

V. Phone/Fax

Practice location:
  • Phone: 608-729-1153
  • Fax:
Mailing address:
  • Phone: 608-729-1153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1226-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: