MEDICARE: MELISSA MARIE JOHANSEN LISW-CP, LCSW-C, MSW

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	1041C0700X	Clinical Social Worker	13535	SC

General Provider Information

NPI Number	:	1750820973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MARIE JOHANSEN LISW-CP, LCSW-C, MSW

Provider Business Mailing Address
First Line	:	4006 POSTAL WAY UNIT A
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3527
Country	:	US
Telephone Number	:	843-258-3976
Fax Number	:	843-277-0730

Provider Business Practice Location Address
First Line	:	1551 21ST AVE N STE 17
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-7496
Country	:	US
Telephone Number	:	843-868-6200
Fax Number	:	843-868-6200

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

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	03/03/2026

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