Provider Demographics
NPI:1477378313
Name:JOHNSON FORD, MELISSA EVONNE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:EVONNE
Last Name:JOHNSON FORD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3426 SOUTHBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-5126
Mailing Address - Country:US
Mailing Address - Phone:843-206-3556
Mailing Address - Fax:
Practice Address - Street 1:300 RAINBOW DR STE 104
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4155
Practice Address - Country:US
Practice Address - Phone:843-206-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-16
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health