Active NPI
Nicole Marie Johnson
- Clinical Psychologist
- Burnsville, MN
National Provider Identifier
1750868212
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- LP6452
- Practice address
- 200 E Travelers TRL Ste 205
Burnsville, MN 55337-4191 - Phone
- (612) 249-0269
- NPI assigned
- Jul 26, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | LP6452 | MN | Primary |
Addresses
Primary practice location
200 E Travelers TRL Ste 205
Burnsville, MN 55337-4191
Mailing address
200 E Travelers TRL Ste 205
Burnsville, MN 55337-4191
Phone (612) 249-0269
Other practice location 1
4660 Slater Rd Ste 210
Eagan, MN 55122
Phone (612) 540-5108
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750868212 | Other | MN | NPI I |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Dec 8, 2023 through Dec 8, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP6452 | MN | MD | Clinical Psychologist |
| 6452 | MN | MD | Nutrition Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1532563200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1599782400000",
"number": "1750868212",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "200 E TRAVELERS TRL STE 205",
"city": "BURNSVILLE",
"state": "MN",
"postal_code": "553374191",
"telephone_number": "612-249-0269"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 E TRAVELERS TRL STE 205",
"city": "BURNSVILLE",
"state": "MN",
"postal_code": "553374191",
"telephone_number": "612-249-0269"
}
],
"practiceLocations": [
{
"address_1": "4660 Slater Rd Ste 210",
"address_purpose": "LOCATION",
"city": "Eagan",
"state": "MN",
"postal_code": "55122",
"country_code": "US",
"telephone_number": "612-540-5108",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "JOHNSON",
"first_name": "NICOLE",
"middle_name": "MARIE",
"name_prefix": "Dr.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-07-26",
"last_updated": "2020-09-11",
"certification_date": "2020-09-11",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "LP6452",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI I",
"identifier": "1750868212",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Burnsville, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.