Provider Demographics
NPI:1659716165
Name:JOHNSON, TANIA MELISSA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:MELISSA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5355 DATE PALM ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-2057
Mailing Address - Country:US
Mailing Address - Phone:321-213-7117
Mailing Address - Fax:
Practice Address - Street 1:5355 DATE PALM ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927
Practice Address - Country:US
Practice Address - Phone:321-213-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2022-06-13
Deactivation Date:2022-05-04
Deactivation Code:
Reactivation Date:2022-06-13
Provider Licenses
StateLicense IDTaxonomies
FLISW 8612104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100826200Medicaid