Healthcare Provider Details

I. General information

NPI: 1376315986
Provider Name (Legal Business Name): MELISSA L. EALBA, LICENSED CLINICAL SOCIAL WORKER, A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 N GRAND AVE STE 210
COVINA CA
91724-4043
US

IV. Provider business mailing address

1343 N GRAND AVE STE 210
COVINA CA
91724-4043
US

V. Phone/Fax

Practice location:
  • Phone: 626-991-5010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MELISSA L EALBA
Title or Position: GROUP OWNER
Credential:
Phone: 626-991-5010