Provider Demographics
NPI:1811618523
Name:MELENDEZ, TAKIESHA INDIGO (LMT)
Entity type:Individual
Prefix:
First Name:TAKIESHA
Middle Name:INDIGO
Last Name:MELENDEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:INDIGO
Other - Middle Name:
Other - Last Name:MELENDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:6104 SEPULVEDA BLVD # 1024
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2503
Mailing Address - Country:US
Mailing Address - Phone:646-833-6331
Mailing Address - Fax:
Practice Address - Street 1:11400 W OLYMPIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1584
Practice Address - Country:US
Practice Address - Phone:800-965-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70065225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist