Provider Demographics
NPI:1811078900
Name:JOHNSON, MELISSA SUE (BASLPA)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BASLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 GARDEN OAKS COVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-862-7227
Mailing Address - Fax:850-862-2421
Practice Address - Street 1:4 JACKSON STREET NE
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-862-7227
Practice Address - Fax:850-862-2421
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI 12692355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant