Provider Demographics
NPI:1932402799
Name:JOHNSON, MALLISSIE V
Entity Type:Individual
Prefix:MS
First Name:MALLISSIE
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MALLISSIE
Other - Middle Name:V
Other - Last Name:WORKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:5563 LIVE OAK ST
Mailing Address - Street 2:#6
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-7556
Mailing Address - Country:US
Mailing Address - Phone:281-682-6498
Mailing Address - Fax:
Practice Address - Street 1:12935 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-5603
Practice Address - Country:US
Practice Address - Phone:281-682-6498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator