Provider Demographics
NPI:1942336953
Name:JOHNSON, MELINDA G (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NELSON STREET
Mailing Address - Street 2:SUITE 130
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1941
Mailing Address - Country:US
Mailing Address - Phone:315-253-6891
Mailing Address - Fax:315-255-0873
Practice Address - Street 1:77 NELSON STREET
Practice Address - Street 2:SUITE 130
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1941
Practice Address - Country:US
Practice Address - Phone:315-253-6891
Practice Address - Fax:315-255-0873
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012442-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0555600001Medicare NSC
RA8928Medicare PIN