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General NPI Number Information
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NPI Number | 1487227229
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Entity Type | Individual
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Provider Name | MATTHEW TYLER JOHNSON LICSW
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Gender | Male
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Dates
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Enumeration Date | 07/20/2021
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 4820 77TH ST W STE 117
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City | EDINA
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State | MN
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Zip | 55435-4809
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Country | US
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Telephone | 612-208-2762
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Fax |
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Provider Business Mailing Address
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Address Line | 800 PRAIRIE CENTER DR STE 210
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-7306
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Country | US
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Telephone | 612-888-0544
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 27484
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License Number State | MN
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