Provider Demographics
NPI:1174027031
Name:AMEZCUA, MELISSA L
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:AMEZCUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 FULTON AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-974-2599
Mailing Address - Fax:
Practice Address - Street 1:1050 FULTON AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-974-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician