Healthcare Provider Details

I. General information

NPI: 1609595271
Provider Name (Legal Business Name): SHELLEY MELISSA BALLA-HAWKINS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 ORCHARD ROAD
DAVIS CA
95616
US

IV. Provider business mailing address

7610 SAN NITA WAY
FAIR OAKS CA
95628-5514
US

V. Phone/Fax

Practice location:
  • Phone: 916-754-3621
  • Fax:
Mailing address:
  • Phone: 916-947-0026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number53570
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: