Provider Demographics
NPI:1467753590
Name:JOHNSON, MELINDA NICOLE (MA, PHD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-1203
Mailing Address - Country:US
Mailing Address - Phone:360-903-1662
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5509
Practice Address - Country:US
Practice Address - Phone:360-619-2226
Practice Address - Fax:360-326-9691
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6110101YP2500X
WALH60133759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional