Provider Demographics
NPI:1609538610
Name:JOHNSON, MELISSA JYNELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JYNELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 CAPOSELE LN
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1309
Mailing Address - Country:US
Mailing Address - Phone:314-495-1443
Mailing Address - Fax:
Practice Address - Street 1:1221 BOONES LICK RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2328
Practice Address - Country:US
Practice Address - Phone:636-946-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010039895224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant