Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1467014043 |
---|---|
Provider Name | Kendra Rose Johnson |
First Address | Minneapolis, MN 55418-2244 |
Second Address | St Louis Park, MN 55416-5275 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2019 |
Last Update Date | 03/07/2019 |