Provider Demographics
NPI:1487310546
Name:JOHNSON, ELIZABETH (LGSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LGSW
Mailing Address - Street 1:1142 LAFOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2028
Mailing Address - Country:US
Mailing Address - Phone:612-888-9065
Mailing Address - Fax:
Practice Address - Street 1:1142 LAFOND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2028
Practice Address - Country:US
Practice Address - Phone:612-888-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN236251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty