Basic Information
| Provider Information | |||||||||
| NPI: | 1215176003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. LP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 FRANCE AVE S | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 FRANCE AVE S | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528352002 | ||||||||
| FaxNumber: | 9528359889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2009 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP5025 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.