Provider Demographics
NPI:1336573104
Name:CHRONISTER, MELODIE ANNE (BASW)
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:ANNE
Last Name:CHRONISTER
Suffix:
Gender:F
Credentials:BASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1706
Mailing Address - Country:US
Mailing Address - Phone:951-533-9480
Mailing Address - Fax:
Practice Address - Street 1:1556 S SULTANA AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-4238
Practice Address - Country:US
Practice Address - Phone:909-418-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8139785390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program