Provider Demographics
NPI:1649317645
Name:JOHNSON, MELISSA ANN (MS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2614
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-2614
Mailing Address - Country:US
Mailing Address - Phone:925-683-6664
Mailing Address - Fax:
Practice Address - Street 1:38970 BLACOW RD STE C
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-7380
Practice Address - Country:US
Practice Address - Phone:925-683-6664
Practice Address - Fax:510-794-8398
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF46116101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist