Provider Demographics
NPI:1215113162
Name:JOHNSON, MELISSA ANN (LCSW, LCAS, CCS)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1417
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-1417
Mailing Address - Country:US
Mailing Address - Phone:336-283-2510
Mailing Address - Fax:336-776-0091
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 112
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9927
Practice Address - Country:US
Practice Address - Phone:336-283-2510
Practice Address - Fax:336-776-0091
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCCS-20157101YA0400X
NCLCAS 3167101YA0400X
NCC0088951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215113162Medicaid
NC1215113162Medicaid