Provider Demographics
NPI:1518507458
Name:TABLADA, MELISA M (CADC II (CA))
Entity Type:Individual
Prefix:MS
First Name:MELISA
Middle Name:M
Last Name:TABLADA
Suffix:
Gender:F
Credentials:CADC II (CA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6721 JELLICO AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5320
Mailing Address - Country:US
Mailing Address - Phone:818-900-9902
Mailing Address - Fax:818-475-1775
Practice Address - Street 1:6721 JELLICO AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5320
Practice Address - Country:US
Practice Address - Phone:818-900-9902
Practice Address - Fax:818-475-1775
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051210118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)