Provider Demographics
NPI:1437889409
Name:ROLLO, MELINDA CAROL
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:CAROL
Last Name:ROLLO
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:PO BOX 1987
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-1987
Mailing Address - Country:US
Mailing Address - Phone:530-626-3105
Mailing Address - Fax:530-642-1233
Practice Address - Street 1:4250 FOWLER LN
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9781
Practice Address - Country:US
Practice Address - Phone:530-626-3106
Practice Address - Fax:530-642-1233
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA131565106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health