Provider Demographics
NPI:1659832434
Name:VYVYAN, MELINDA (LMFT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:VYVYAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 VIRGINIA RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-5938
Mailing Address - Country:US
Mailing Address - Phone:310-694-6490
Mailing Address - Fax:
Practice Address - Street 1:714 W OLYMPIC BLVD STE 742
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1026
Practice Address - Country:US
Practice Address - Phone:310-712-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99496106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist