Provider Demographics
NPI:1255013504
Name:AUTHENTIC SELF THERAPY PLLC
Entity type:Organization
Organization Name:AUTHENTIC SELF THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC; LADC/LMAC
Authorized Official - Phone:320-855-6557
Mailing Address - Street 1:103 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1207
Mailing Address - Country:US
Mailing Address - Phone:320-855-6557
Mailing Address - Fax:320-238-7456
Practice Address - Street 1:103 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1207
Practice Address - Country:US
Practice Address - Phone:320-855-6557
Practice Address - Fax:320-238-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)