Provider Demographics
NPI:1437535929
Name:JOHNSON, MELISSA M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:IGNOFFO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:12 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9637
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:815-756-2944
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IL149.0211161041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362771343001Medicaid