Basic Information
| Provider Information | |||||||||
| NPI: | 1821603853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MSW, LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 UPLAND LN N | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9600 UPLAND LN N | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 20199 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.