Provider Demographics
NPI:1063456093
Name:JOHNSTON, MELINDA MARIS (MA LLP LLPC)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIS
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MA LLP LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 HOLIDAY TER
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2196
Mailing Address - Country:US
Mailing Address - Phone:269-372-4140
Mailing Address - Fax:269-372-0390
Practice Address - Street 1:5340 HOLIDAY TER
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2196
Practice Address - Country:US
Practice Address - Phone:269-372-4140
Practice Address - Fax:269-372-0390
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009761101YM0800X
MI6301011212103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0897457OtherBLUE CROSS BLUE SHIELD OF MICHIGAN