Provider Demographics
NPI:1861512113
Name:LEW, MELODIE L (MFT)
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:L
Last Name:LEW
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-0721
Mailing Address - Country:US
Mailing Address - Phone:650-532-0508
Mailing Address - Fax:650-573-1764
Practice Address - Street 1:126 2ND AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3860
Practice Address - Country:US
Practice Address - Phone:650-532-0508
Practice Address - Fax:650-573-1764
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2009-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44082106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-8194389OtherEIN