Provider Demographics
NPI:1942840905
Name:TINES, MELISSA SONYA (MSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SONYA
Last Name:TINES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HUGHES WAY STE C100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1808
Mailing Address - Country:US
Mailing Address - Phone:213-385-5100
Mailing Address - Fax:
Practice Address - Street 1:1500 HUGHES WAY STE C100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-1808
Practice Address - Country:US
Practice Address - Phone:213-385-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW92688101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health