Healthcare Provider Details

I. General information

NPI: 1508145772
Provider Name (Legal Business Name): MELISSA MARIE WILLARD LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 POLLASKY AVE STE D
CLOVIS CA
93612-1159
US

IV. Provider business mailing address

106 POLLASKY AVE STE D
CLOVIS CA
93612-1159
US

V. Phone/Fax

Practice location:
  • Phone: 559-203-3775
  • Fax:
Mailing address:
  • Phone: 559-355-7491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number93335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: