Provider Demographics
NPI:1912528514
Name:FEDORYK, MELISSA WELLS (MA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:WELLS
Last Name:FEDORYK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BRETAGNE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1032
Mailing Address - Country:US
Mailing Address - Phone:949-307-3533
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE ST STE 105
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2805
Practice Address - Country:US
Practice Address - Phone:949-415-4979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist