Provider Demographics
NPI:1467753590
Name:JOHNSON, MELINDA NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-1203
Mailing Address - Country:US
Mailing Address - Phone:360-903-1662
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR STE B
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6157
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:360-567-2212
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60133759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health