Provider Demographics
NPI:1437396066
Name:JOHNSON, MELODY L (LMT)
Entity Type:Individual
Prefix:MS
First Name:MELODY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
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 6687
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-6687
Mailing Address - Country:US
Mailing Address - Phone:503-279-0205
Mailing Address - Fax:503-279-0206
Practice Address - Street 1:1201 SW12TH AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97250
Practice Address - Country:US
Practice Address - Phone:503-279-0205
Practice Address - Fax:503-279-0206
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3383225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist