Provider Demographics
NPI:1912244757
Name:HUDSON-GROGAN, MELANIE RACHEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:RACHEL
Last Name:HUDSON-GROGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MELANIE
Other - Middle Name:R
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:11655 GORHAM AVE
Mailing Address - Street 2:#5
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4748
Mailing Address - Country:US
Mailing Address - Phone:310-701-5103
Mailing Address - Fax:
Practice Address - Street 1:10323 SANTA MONICA BLVD STE 111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5056
Practice Address - Country:US
Practice Address - Phone:310-701-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist