Basic Information
Provider Information | |||||||||
NPI: | 1518094895 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEREZ-MELENDEZ | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | HAYDEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEREZ-MELENDEZ | ||||||||
OtherFirstName: | MARIA | ||||||||
OtherMiddleName: | HAYDEE | ||||||||
OtherNamePrefix: | PROF. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1160 S GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917405000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263355980 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1160 S GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917405000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263355980 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2007 | ||||||||
LastUpdateDate: | 12/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 48298 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7181 | 01 | CA | MFT INTERN NUMBER | OTHER | TRI3181 | 01 | CA | MIS NUMBER | OTHER |