Provider Demographics
NPI:1073997243
Name:SAMPLES, MELANI CHRISTINE
Entity Type:Individual
Prefix:MRS
First Name:MELANI
Middle Name:CHRISTINE
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MELANI
Other - Middle Name:CHRISTINE
Other - Last Name:MATJE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12818 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3165
Mailing Address - Country:US
Mailing Address - Phone:951-204-1389
Mailing Address - Fax:
Practice Address - Street 1:12818 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3165
Practice Address - Country:US
Practice Address - Phone:951-204-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 87083106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist