Provider Demographics
NPI:1265455893
Name:VANTESLAAR, MELISSA (MS)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:VANTESLAAR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MODDISON AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2416
Mailing Address - Country:US
Mailing Address - Phone:916-833-1476
Mailing Address - Fax:
Practice Address - Street 1:1674 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-4910
Practice Address - Country:US
Practice Address - Phone:916-890-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48138106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008462OtherMEDICAL PROVIDER