Provider Demographics
NPI:1417355322
Name:MELITA TRAVIS JOHNSON, LMSW, CCDP
Entity Type:Organization
Organization Name:MELITA TRAVIS JOHNSON, LMSW, CCDP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVIS JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CCDP
Authorized Official - Phone:616-481-9337
Mailing Address - Street 1:1130 ELMDALE AVE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801063274251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health