Provider Demographics
NPI:1396234456
Name:JOHNSTON, MELISSA (COTA/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21999 KERN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9295
Mailing Address - Country:US
Mailing Address - Phone:574-292-0927
Mailing Address - Fax:
Practice Address - Street 1:1215 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5000
Practice Address - Country:US
Practice Address - Phone:574-208-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002514A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant