Provider Demographics
NPI:1235304981
Name:ROBERT E. JOHNSON, INC.
Entity type:Organization
Organization Name:ROBERT E. JOHNSON, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:651-628-0947
Mailing Address - Street 1:2579 HAMLINE AVE N
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3186
Mailing Address - Country:US
Mailing Address - Phone:651-628-0947
Mailing Address - Fax:651-636-2922
Practice Address - Street 1:2579 HAMLINE AVE N
Practice Address - Street 2:SUITE D
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3186
Practice Address - Country:US
Practice Address - Phone:651-628-0947
Practice Address - Fax:651-636-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1796261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN099347600Medicaid
MN1225134687OtherINDIVIDUAL NPI ALREADY ISSUED MEDICARE INFORMED US NEEDED GROUP ALSO
MN620000282Medicare PIN