Provider Demographics
NPI:1134167216
Name:JOHNSON, MELISSA JILL (PT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JILL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 NEW UNIVERSITY TRL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-1527
Mailing Address - Country:US
Mailing Address - Phone:678-455-6391
Mailing Address - Fax:678-455-6393
Practice Address - Street 1:6920 MCGINNIS FERRY RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1258
Practice Address - Country:US
Practice Address - Phone:770-495-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT5672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA592156OtherBCBS GA
GA65BBCJSMedicare ID - Type Unspecified