Provider Demographics
NPI:1720426489
Name:WILSON, MELINDA RACHEL (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:RACHEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18618 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4030
Mailing Address - Country:US
Mailing Address - Phone:818-309-0652
Mailing Address - Fax:
Practice Address - Street 1:18618 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4030
Practice Address - Country:US
Practice Address - Phone:818-309-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist