Provider Demographics
NPI:1841575636
Name:LAVERTY, MELISSA ANN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:LAVERTY
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 1:1529 SAINT FRANCIS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3929
Mailing Address - Country:US
Mailing Address - Phone:707-480-0441
Mailing Address - Fax:
Practice Address - Street 1:2227 CAPRICORN WAY STE 207
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5486
Practice Address - Country:US
Practice Address - Phone:707-565-4939
Practice Address - Fax:707-565-4907
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103058106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist