Provider Demographics
NPI:1639516602
Name:BENNETT, MELANIE BERNICE
Entity Type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:BERNICE
Last Name:BENNETT
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 1:8461 SAN PABLO DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3022
Mailing Address - Country:US
Mailing Address - Phone:727-365-7762
Mailing Address - Fax:
Practice Address - Street 1:902 S MYRTLE AVENUE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016
Practice Address - Country:US
Practice Address - Phone:626-357-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA30334103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program