Basic Information
| Provider Information | |||||||||
| NPI: | 1215304738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMFT / #769 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 COON RAPIDS BLVD. #200 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637843008 | ||||||||
| FaxNumber: | 7637843647 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 OSBORNE RD NE STE 260 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554322866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637843008 | ||||||||
| FaxNumber: | 7632363821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 769 | 01 | MN | LMFT | OTHER |