=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922208834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE JOHNSON PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2007
-----------------------------------------------------
Last Update Date | 07/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 HILL RD SUITE 18
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-897-2700
-----------------------------------------------------
Fax | 415-897-6450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 HILL RD SUITE 18
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94947-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-897-2700
-----------------------------------------------------
Fax | 415-897-6450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 16704
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------