Provider Demographics
NPI:1215304738
Name:JOHNSON, BRUCE A (LMFT / #769)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT / #769
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 COON RAPIDS BLVD. #200
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-784-3008
Mailing Address - Fax:763-784-3647
Practice Address - Street 1:480 OSBORNE RD NE STE 260
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55432-2866
Practice Address - Country:US
Practice Address - Phone:763-784-3008
Practice Address - Fax:763-236-3821
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN769OtherLMFT