Provider Demographics
NPI:1023767753
Name:JOHANSON, ANNA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MADISON AVE STE 352
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4458
Mailing Address - Country:US
Mailing Address - Phone:507-389-8502
Mailing Address - Fax:507-625-3928
Practice Address - Street 1:1400 MADISON AVE STE 352
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4458
Practice Address - Country:US
Practice Address - Phone:507-387-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN157881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical