Healthcare Provider Details

I. General information

NPI: 1518269612
Provider Name (Legal Business Name): MELISSA A JOHNSTON LAT, CEAS, CFCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR REHAB SERVICES
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR REHAB SERVICES
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5534
  • Fax: 920-361-5910
Mailing address:
  • Phone: 920-361-5534
  • Fax: 920-361-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number584-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: