Basic Information
| Provider Information | |||||||||
| NPI: | 1205189545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7155984881 | ||||||||
| Practice Location | |||||||||
| Address1: | 10752 BEAL AVE | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548436435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342522 | ||||||||
| FaxNumber: | 7156342533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 101YP2500X | 4560-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.