Healthcare Provider Details

I. General information

NPI: 1306291869
Provider Name (Legal Business Name): MELVINIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5233 E BEVERLY BLVD
LOS ANGELES CA
90022-2020
US

IV. Provider business mailing address

5233 E BEVERLY BLVD
LOS ANGELES CA
90022-2020
US

V. Phone/Fax

Practice location:
  • Phone: 323-724-6911
  • Fax:
Mailing address:
  • Phone: 323-724-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1584111024
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: