Provider Demographics
NPI:1669134482
Name:GREEN, MELISSA RUTH
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RUTH
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24953 PASEO DE VALENCIA BLDG B, STE. 1B
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4340
Mailing Address - Country:US
Mailing Address - Phone:949-540-0170
Mailing Address - Fax:949-540-0173
Practice Address - Street 1:24953 PASEO DE VALENCIA BLDG B, STE. 1B
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4340
Practice Address - Country:US
Practice Address - Phone:949-540-0170
Practice Address - Fax:949-540-0173
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)