Provider Demographics
NPI:1700462900
Name:GENSAW, MELANIE ROR-REE (LCSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ROR-REE
Last Name:GENSAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 S FORTUNA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3009
Mailing Address - Country:US
Mailing Address - Phone:707-392-3780
Mailing Address - Fax:
Practice Address - Street 1:934 S FORTUNA BLVD STE B
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3009
Practice Address - Country:US
Practice Address - Phone:707-392-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92891101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)