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General NPI Number Information
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NPI Number | 1215752274
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Entity Type | Individual
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Provider Name | TYLER JOHNSON LICSW
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Gender | Male
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Dates
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Enumeration Date | 11/15/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 16123 GRANT UTLEY AVE NW
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City | CASS LAKE
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State | MN
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Zip | 56633
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Country | US
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Telephone | 218-335-3050
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Fax |
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Provider Business Mailing Address
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Address Line | 34335 MUSKRAT RD
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City | LAPORTE
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State | MN
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Zip | 56461-4517
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 31432
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License Number State | MN
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