Provider Demographics
NPI:1285257683
Name:JOHNSON, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:MANDERFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12950 ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1921
Mailing Address - Country:US
Mailing Address - Phone:651-343-4780
Mailing Address - Fax:
Practice Address - Street 1:18000 W SARAH LN STE 210
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5840
Practice Address - Country:US
Practice Address - Phone:262-267-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1253-124106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist