Provider Demographics
NPI:1801416409
Name:SMITH, MELISSA SUZANNE (MA EDS, PPS)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:SUZANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA EDS, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 SILK TREE LN
Mailing Address - Street 2:
Mailing Address - City:COOL
Mailing Address - State:CA
Mailing Address - Zip Code:95614-9481
Mailing Address - Country:US
Mailing Address - Phone:530-401-2917
Mailing Address - Fax:
Practice Address - Street 1:1000 LOW GAP RD
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3737
Practice Address - Country:US
Practice Address - Phone:707-472-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool