Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 6401009761 | MI |
N | 103TC1900X | Counseling Psychologist | 6301011212 | MI |
NPI | 1063456093 |
---|---|
Provider Name | Melinda Maris Johnston |
First Address | Kalamazoo, MI 49009-2196 |
Second Address | Kalamazoo, MI 49009-2196 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 14/07/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0897457 | BLUE CROSS BLUE SHIELD OF MICHIGAN (01) | MI |