Provider Demographics
NPI:1902364250
Name:JOHNSON, MELANIE (MS/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 STATE ROAD 83
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-8807
Mailing Address - Country:US
Mailing Address - Phone:920-342-0847
Mailing Address - Fax:
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-447-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3408-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist