Provider Demographics
NPI:1831757467
Name:MELGOZA RUMBO, LIZBETH DEL CARMEN
Entity type:Individual
Prefix:MISS
First Name:LIZBETH
Middle Name:DEL CARMEN
Last Name:MELGOZA RUMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LIZBETH
Other - Middle Name:DEL CARMEN
Other - Last Name:MELGOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1876 LA PORTE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-2045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5820 STONERIDGE MALL RD STE 205
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3347
Practice Address - Country:US
Practice Address - Phone:408-250-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty