Provider Demographics
NPI:1932223245
Name:JOHANNSEN, MELISSA (MFT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JOHANNSEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9089 BASELINE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1295
Mailing Address - Country:US
Mailing Address - Phone:909-980-3567
Mailing Address - Fax:909-989-3932
Practice Address - Street 1:9089 BASELINE RD STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1295
Practice Address - Country:US
Practice Address - Phone:909-980-3567
Practice Address - Fax:909-989-3932
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30931106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist