Healthcare Provider Details

I. General information

NPI: 1376936104
Provider Name (Legal Business Name): MELITA TRAVIS JOHNSON LMSW, CCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE STE 103
GRAND RAPIDS MI
49546-8602
US

IV. Provider business mailing address

1130 ELMDALE ST NE
GRAND RAPIDS MI
49525-2632
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-9337
  • Fax: 616-719-3119
Mailing address:
  • Phone: 616-481-9337
  • Fax: 616-719-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801063274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: