Provider Demographics
NPI:1508373788
Name:JOHNSON, MELANIE LAURA (LICSW, PIP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LAURA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW, PIP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW, PIP
Mailing Address - Street 1:PO BOX 660843
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35266-0843
Mailing Address - Country:US
Mailing Address - Phone:205-837-8220
Mailing Address - Fax:
Practice Address - Street 1:4289 GLASCOTT XING
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-6376
Practice Address - Country:US
Practice Address - Phone:205-837-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3634C1041C0700X
AL1365-3634C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty