MEDICARE: MELISSA JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	OTA10749	FL

General Provider Information

NPI Number	:	1316513617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA JOHNSON

Provider Business Mailing Address
First Line	:	4580 ALDER DR
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-9255
Country	:	US
Telephone Number	:	386-451-7957
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 PARC HILL BLVD
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8029
Country	:	US
Telephone Number	:	386-960-8277
Fax Number	:	857-290-9134

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2021
Last Update Date	:	05/28/2021

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Directions to “ MELISSA JOHNSON ” Practice Location

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