Provider Demographics
NPI:1679295083
Name:MERLOS, MELVIN DAVID
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:DAVID
Last Name:MERLOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4502
Mailing Address - Country:US
Mailing Address - Phone:707-342-5423
Mailing Address - Fax:
Practice Address - Street 1:2460 CLAY BANK RD BLDG 8
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1655
Practice Address - Country:US
Practice Address - Phone:707-701-0825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142799106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist