Provider Demographics
NPI:1255946216
Name:JOHNSON, MELISSA MARIE (MA, LPC, NCC, ATR)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LPC, NCC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 VOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2019
Mailing Address - Country:US
Mailing Address - Phone:973-901-9428
Mailing Address - Fax:973-901-9427
Practice Address - Street 1:9 VOSE AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079
Practice Address - Country:US
Practice Address - Phone:973-901-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00707200101YM0800X, 106H00000X, 101YP2500X
133N00000X, 221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1578927851Medicaid