Provider Demographics
NPI:1871302604
Name:JOHNSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7941 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1953
Mailing Address - Country:US
Mailing Address - Phone:317-726-2121
Mailing Address - Fax:
Practice Address - Street 1:2648 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-2934
Practice Address - Country:US
Practice Address - Phone:219-510-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health