Provider Demographics
NPI:1225231780
Name:CROCKER, MELOUNIE PALANA
Entity Type:Individual
Prefix:
First Name:MELOUNIE
Middle Name:PALANA
Last Name:CROCKER
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 1:1831 PEARL ST
Mailing Address - Street 2:# 4
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2732
Mailing Address - Country:US
Mailing Address - Phone:310-450-1120
Mailing Address - Fax:
Practice Address - Street 1:ONE CIVIC PLAZA
Practice Address - Street 2:SUITE 625
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:310-549-4500
Practice Address - Fax:310-549-4700
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 6400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant