Basic Information
| Provider Information | |||||||||
| NPI: | 1235486796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LISW, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LICDC.131172 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | S1101198 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I.1303185 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0176627 | 05 | OH | MEDICAID |