Provider Demographics
NPI:1114485414
Name:MELENDEZ, ALEXIS (MED)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:MELENDEZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 PLAZA DE NOCHE APT 13
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2974
Mailing Address - Country:US
Mailing Address - Phone:714-743-0428
Mailing Address - Fax:
Practice Address - Street 1:10221 SLATER AVE STE 114
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4744
Practice Address - Country:US
Practice Address - Phone:909-268-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10102106S00000X
CA1-21-47810103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10102OtherQASP