Provider Demographics
NPI:1104514496
Name:JOHNSON, MELINDA ELAINE (LMFT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ELAINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61540 SE COLIMA ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3873
Mailing Address - Country:US
Mailing Address - Phone:478-719-0112
Mailing Address - Fax:541-229-1249
Practice Address - Street 1:131 NW HAWTHORNE AVENUE
Practice Address - Street 2:STE 103
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2957
Practice Address - Country:US
Practice Address - Phone:541-697-4863
Practice Address - Fax:541-229-1249
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT2227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health