Provider Demographics
NPI:1376068148
Name:MAGALLANES, MELISSA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:MAGALLANES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 FOOTHILL BLVD STE B266
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2901
Mailing Address - Country:US
Mailing Address - Phone:626-408-0919
Mailing Address - Fax:
Practice Address - Street 1:2105 FOOTHILL BLVD STE B266
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2901
Practice Address - Country:US
Practice Address - Phone:626-408-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA390200000X
CAPSY34292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program