Provider Demographics
NPI:1477085835
Name:KNOTT, MELY
Entity Type:Individual
Prefix:
First Name:MELY
Middle Name:
Last Name:KNOTT
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 1:710 E SAN YSIDRO BLVD APT 872
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3123
Mailing Address - Country:US
Mailing Address - Phone:619-770-9411
Mailing Address - Fax:
Practice Address - Street 1:710 E SAN YSIDRO BLVD APT 872
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-3123
Practice Address - Country:US
Practice Address - Phone:619-770-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB312587106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician