Provider Demographics
NPI:1023594298
Name:JOHNSON, MELVIN (CAC-AD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10903 INDIAN HEAD HWY STE 504
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-4012
Mailing Address - Country:US
Mailing Address - Phone:240-766-4194
Mailing Address - Fax:301-485-0363
Practice Address - Street 1:10903 INDIAN HEAD HWY STE 504
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4012
Practice Address - Country:US
Practice Address - Phone:240-766-4194
Practice Address - Fax:301-485-0363
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1032101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)