Provider Demographics
NPI:1891305199
Name:JOHNS, MELISSA ANN (LMT, PTA, CDP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:JOHNS
Suffix:
Gender:F
Credentials:LMT, PTA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 1/2 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8767
Mailing Address - Country:US
Mailing Address - Phone:810-877-3344
Mailing Address - Fax:
Practice Address - Street 1:909 1/2 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8767
Practice Address - Country:US
Practice Address - Phone:810-877-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501012030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist