Provider Demographics
NPI:1265764641
Name:JOHNSON, MATTHEW (MA LPCC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 SE MAIN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2151
Mailing Address - Country:US
Mailing Address - Phone:612-886-2524
Mailing Address - Fax:612-886-2538
Practice Address - Street 1:219 SE MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414
Practice Address - Country:US
Practice Address - Phone:612-886-2524
Practice Address - Fax:612-886-2538
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional