Basic Information
| Provider Information | |||||||||
| NPI: | 1790812162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETROSSIAN | ||||||||
| FirstName: | MELITA | ||||||||
| MiddleName: | TALENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827433 | ||||||||
| FaxNumber: | 3105827495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 20TH ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105827433 | ||||||||
| FaxNumber: | 3105827495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | A120954 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1790812162 | 05 | CA | MEDICAID |