1417119884 NPI number — MELANIE JOHNSON, LCSW, LLC

Table of content: WENDY VANNESSA MARTIN CADCII (NPI 1194916064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417119884 NPI number — MELANIE JOHNSON, LCSW, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELANIE JOHNSON, LCSW, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417119884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9979 ORANGE BLOSSOM TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-7447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-863-2593
Provider Business Mailing Address Fax Number:
317-863-2602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 BELVEDERE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46901-5627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-453-4527
Provider Business Practice Location Address Fax Number:
317-863-2602
Provider Enumeration Date:
06/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BEESON
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER, BILLING CO.
Authorized Official Telephone Number:
317-863-2593

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34004095A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1871574475 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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