MEDICARE: OMIKA JOHNSON LADC

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	306854	MN

General Provider Information

NPI Number	:	1164386595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMIKA JOHNSON LADC

Provider Business Mailing Address
First Line	:	1500 GOLDEN VALLEY RD
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-3139
Country	:	US
Telephone Number	:	612-520-9185
Fax Number	:	612-520-0047

Provider Business Practice Location Address
First Line	:	1500 GOLDEN VALLEY RD
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-3139
Country	:	US
Telephone Number	:	612-520-9185
Fax Number	:	612-520-0047

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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