Provider Demographics
NPI:1679833487
Name:JOHNSON, MELANIE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 DAKOTA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3742
Mailing Address - Country:US
Mailing Address - Phone:847-220-8428
Mailing Address - Fax:
Practice Address - Street 1:600 DAKOTA ST
Practice Address - Street 2:SUITE B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3742
Practice Address - Country:US
Practice Address - Phone:847-220-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000967106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist