Healthcare Provider Details

I. General information

NPI: 1972436632
Provider Name (Legal Business Name): MELISSA ANNE ACEVEDO LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 S 51ST ST STE 150
PHOENIX AZ
85044-5229
US

IV. Provider business mailing address

7117 W PEORIA AVE
PEORIA AZ
85345-6015
US

V. Phone/Fax

Practice location:
  • Phone: 909-767-6061
  • Fax:
Mailing address:
  • Phone: 909-767-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: