Basic Information
Provider Information | |||||||||
NPI: | 1295107985 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | MELINDA | ||||||||
MiddleName: | JOHNSON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MAED | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 SAINT LANDRY ST | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705064630 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372105145 | ||||||||
FaxNumber: | 3372105450 | ||||||||
Practice Location | |||||||||
Address1: | 700 SAINT LANDRY ST | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 70506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372105145 | ||||||||
FaxNumber: | 3372105450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2015 | ||||||||
LastUpdateDate: | 08/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.