Provider Demographics
NPI:1891809786
Name:CAMPITELLI-SMITH, MELISSA MARCIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARCIA
Last Name:CAMPITELLI-SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:MARCIA
Other - Last Name:CAMPITELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92609-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1370 VALLEY VISTA DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3911
Practice Address - Country:US
Practice Address - Phone:909-860-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical