Provider Demographics
NPI:1982818894
Name:JOHNSON, MELISSA KAYE (PT, CWS)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:KAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9992 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8183
Mailing Address - Country:US
Mailing Address - Phone:770-719-7196
Mailing Address - Fax:770-710-7189
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-7196
Practice Address - Fax:770-719-7189
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist