Provider Demographics
NPI:1518269612
Name:JOHNSTON, MELISSA A (LAT, CEAS, CFCE)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:LAT, CEAS, CFCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:REHAB SERVICES
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5534
Mailing Address - Fax:920-361-5910
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:REHAB SERVICES
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5534
Practice Address - Fax:920-361-5910
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI584-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer