Provider Demographics
NPI:1891125019
Name:KALLSEN, MELISSA RENEE (LAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:KALLSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 LINCOLN BLVD
Mailing Address - Street 2:SUITE #201 C
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2826
Mailing Address - Country:US
Mailing Address - Phone:310-428-6011
Mailing Address - Fax:
Practice Address - Street 1:122 LINCOLN BLVD
Practice Address - Street 2:SUITE #201 C
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2826
Practice Address - Country:US
Practice Address - Phone:310-428-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15533171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist