Provider Demographics
NPI:1013685817
Name:MELGAREJO, INDIRA MARU (MS)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:MARU
Last Name:MELGAREJO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SLEATER KINNEY RD SE STE B353
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1150
Mailing Address - Country:US
Mailing Address - Phone:360-401-9720
Mailing Address - Fax:
Practice Address - Street 1:700 SLEATER KINNEY RD SE STE B353
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1150
Practice Address - Country:US
Practice Address - Phone:360-401-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61123378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health