Provider Demographics
NPI:1477094027
Name:PALACIOS, MELCHICEDEC (CMT, ACSW)
Entity Type:Individual
Prefix:
First Name:MELCHICEDEC
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:CMT, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2162
Mailing Address - Country:US
Mailing Address - Phone:310-316-1610
Mailing Address - Fax:
Practice Address - Street 1:3245 SANTA FE AVE APT 62
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-2414
Practice Address - Country:US
Practice Address - Phone:310-617-6432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1018151041C0700X
CA69971225700000X, 225700000X
CA66728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82-0823826OtherEIN