Provider Demographics
NPI:1063008449
Name:ANDERSON, MELODY JILL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELODY
Middle Name:JILL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24483
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-0483
Mailing Address - Country:US
Mailing Address - Phone:310-285-9410
Mailing Address - Fax:
Practice Address - Street 1:11433 ROCHESTER AVE APT 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2411
Practice Address - Country:US
Practice Address - Phone:310-285-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA286091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28609OtherLCSW CALIFORNIA LICENSE