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General NPI Number Information
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NPI Number | 1841383643
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Entity Type | Individual
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Provider Name | LYNNE ELLEN JOHNSON MS LP
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Gender | Female
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 523 N 3RD ST
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City | BRAINERD
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State | MN
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Zip | 56401-3054
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Country | US
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Telephone | 218-828-7379
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Fax | 218-828-7390
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Provider Business Mailing Address
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Address Line | 4068 GREEN GABLES RD
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City | BRAINERD
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State | MN
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Zip | 56401-7946
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Country | US
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Telephone | 218-829-6687
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Fax | 218-829-9555
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP2864
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License Number State | MN
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