Provider Demographics
NPI:1619092608
Name:STANDER, MELISSA MARY (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARY
Last Name:STANDER
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12465 GREENE AVE.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066
Mailing Address - Country:US
Mailing Address - Phone:310-612-9351
Mailing Address - Fax:
Practice Address - Street 1:877 NORTH DOUGLAS STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:424-835-1336
Practice Address - Fax:310-536-0215
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist