Provider Demographics
NPI:1194056812
Name:JOHNSON, LAURA J (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:STILLNOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:5047 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1309
Mailing Address - Country:US
Mailing Address - Phone:612-747-1325
Mailing Address - Fax:
Practice Address - Street 1:410 E 48TH ST STE 2
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419
Practice Address - Country:US
Practice Address - Phone:612-747-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN191911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN100263198Medicaid