Provider Demographics
NPI:1861664773
Name:LOPEZ, MELISSA MARIE (MFT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:LOPEZ
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 1:1111 S. GRAND AVE.
Mailing Address - Street 2:UNIT #1014
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015
Mailing Address - Country:US
Mailing Address - Phone:323-596-7332
Mailing Address - Fax:208-545-3041
Practice Address - Street 1:3171 LOS FELIZ BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1527
Practice Address - Country:US
Practice Address - Phone:323-506-7332
Practice Address - Fax:208-545-3041
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45263106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist