Provider Demographics
NPI:1922573203
Name:MELCON, KIMBERLY D (LMFT #88001)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:D
Last Name:MELCON
Suffix:
Gender:F
Credentials:LMFT #88001
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7658 TOPANGA CANYON BLVD UNIT 112
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-5589
Mailing Address - Country:US
Mailing Address - Phone:818-205-3844
Mailing Address - Fax:
Practice Address - Street 1:28310 ROADSIDE DR STE 121
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4949
Practice Address - Country:US
Practice Address - Phone:818-205-3844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88001106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist