1154310126 NPI number — TIM JOHNSON M.S.W., LICSW & LMFT

Table of content: TIM JOHNSON M.S.W., LICSW & LMFT (NPI 1154310126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154310126 NPI number — TIM JOHNSON M.S.W., LICSW & LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
TIM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.W., LICSW & LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154310126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8669 EAGLE POINT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ELMO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55042-8628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-379-0444
Provider Business Mailing Address Fax Number:
651-379-0448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8669 EAGLE POINT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ELMO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55042-8628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-379-0444
Provider Business Practice Location Address Fax Number:
651-379-0448
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  409 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 157 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 563T1JO . This is a "BCBS ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-13403 . This is a "MEDICA/UBH ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 247927 . This is a "COMPSYCH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: O95457000 . This is a "MAGELLAN/AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 181557200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69599 . This is a "VALUE OPTIONS ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 102218 . This is a "BHP/FAIRVIEW ID#" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP45669 . This is a "HEALTH PARTNERS ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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