Basic Information
| Provider Information | |||||||||
| NPI: | 1467742346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MELYSSA | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 LACRUE AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193421062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005787906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1878 AVENIDA ARAGON | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920566203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195661465 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 8419 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.