Provider Demographics
NPI:1730360207
Name:JOHNSON, LISA MARIE (PSYD, LMFT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE W STE 12
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3952
Mailing Address - Country:US
Mailing Address - Phone:651-379-5157
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 12
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3952
Practice Address - Country:US
Practice Address - Phone:651-379-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1711106H00000X
MNLP5255103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist