Provider Demographics
NPI:1578343406
Name:DE LA ROSA, MELODY RENAE
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:RENAE
Last Name:DE LA ROSA
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 1:9939 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-3036
Mailing Address - Country:US
Mailing Address - Phone:909-712-8604
Mailing Address - Fax:
Practice Address - Street 1:9939 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-3036
Practice Address - Country:US
Practice Address - Phone:909-712-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst