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NPI Code Detail

MEDICARE: TIM JOHNSON M.S.W., LICSW & LMFT

MEDICARE: TIM JOHNSON M.S.W., LICSW & LMFT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker409MN
2106H00000XMarriage & Family Therapist157MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1563T1JOOTHERMNBCBS ID#
262-13403OTHERMNMEDICA/UBH ID#
3247927OTHERMNCOMPSYCH
4O95457000OTHERMAGELLAN/AETNA
5MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
669599OTHERMNVALUE OPTIONS ID#
7102218OTHERBHP/FAIRVIEW ID#
8HP45669OTHERMNHEALTH PARTNERS ID#

General Provider Information

NPI Number : 1154310126
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIM JOHNSON M.S.W., LICSW & LMFT
Provider Business Mailing Address
First Line : 8669 EAGLE POINT BLVD
Second Line :
City : LAKE ELMO
State : MN
Zip : 55042-8628
Country : US
Telephone Number : 651-379-0444
Fax Number : 651-379-0448
Provider Business Practice Location Address
First Line : 8669 EAGLE POINT BLVD
Second Line :
City : LAKE ELMO
State : MN
Zip : 55042-8628
Country : US
Telephone Number : 651-379-0444
Fax Number : 651-379-0448
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2005
Last Update Date : 12/23/2011

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