Provider Demographics
NPI:1376936104
Name:TRAVIS JOHNSON, MELITA (LMSW, CCDP)
Entity Type:Individual
Prefix:MS
First Name:MELITA
Middle Name:
Last Name:TRAVIS JOHNSON
Suffix:
Gender:F
Credentials:LMSW, CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 ELMDALE ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2632
Mailing Address - Country:US
Mailing Address - Phone:616-481-9337
Mailing Address - Fax:616-719-3119
Practice Address - Street 1:770 KENMOOR AVE SE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8602
Practice Address - Country:US
Practice Address - Phone:616-481-9337
Practice Address - Fax:616-719-3119
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010632741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical