Provider Demographics
NPI:1699864660
Name:JOHNSON, TIMOTHY ROGER (MA LMFT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ROGER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-0284
Mailing Address - Country:US
Mailing Address - Phone:320-905-0795
Mailing Address - Fax:320-205-0030
Practice Address - Street 1:217 INDUSTRIAL DR SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-905-0795
Practice Address - Fax:320-200-7480
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1071101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health