Provider Demographics
NPI:1760151716
Name:FERNANDEZ, MELISSA (SCHOOL PSY)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:SCHOOL PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 E RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-1628
Mailing Address - Country:US
Mailing Address - Phone:626-372-9485
Mailing Address - Fax:
Practice Address - Street 1:256 E RALSTON AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-1628
Practice Address - Country:US
Practice Address - Phone:626-372-9485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10156205103TS0200X
CA210076076103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool