Basic Information
| Provider Information | |||||||||
| NPI: | 1154310126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TIM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S.W., LICSW & LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8669 EAGLE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELMO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550428628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513790444 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Practice Location | |||||||||
| Address1: | 8669 EAGLE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELMO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550428628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513790444 | ||||||||
| FaxNumber: | 6513790448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 12/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 409 | MN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 157 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 563T1JO | 01 | MN | BCBS ID# | OTHER | 62-13403 | 01 | MN | MEDICA/UBH ID# | OTHER | 247927 | 01 | MN | COMPSYCH | OTHER | O95457000 | 01 | MAGELLAN/AETNA | OTHER | 181557200 | 05 | MN | MEDICAID | 69599 | 01 | MN | VALUE OPTIONS ID# | OTHER | 102218 | 01 | BHP/FAIRVIEW ID# | OTHER | HP45669 | 01 | MN | HEALTH PARTNERS ID# | OTHER |