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General NPI Number Information
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NPI Number | 1881127272
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Entity Type | Individual
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Provider Name | BROOKE JOHNSON LADC
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Gender | Female
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Dates
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Enumeration Date | 04/04/2017
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Last Update Date | 04/28/2017
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Provider Practice Location Address
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Address Line | 69 EXCHANGE ST W
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City | SAINT PAUL
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State | MN
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Zip | 55102-1004
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Country | US
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Telephone | 651-232-4284
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Fax | 651-326-3900
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Provider Business Mailing Address
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Address Line | 5226 LAKEVIEW AVE
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-7811
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Country | US
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Telephone | 952-484-7100
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 304552
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License Number State | MN
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