Provider Demographics
NPI:1356950356
Name:JOHNSON, MELVENA
Entity type:Individual
Prefix:
First Name:MELVENA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ALLEGHENY ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 RIDGE RD STE 2D-E
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1933
Practice Address - Country:US
Practice Address - Phone:312-609-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007100225700000X
IL227021103225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist