Healthcare Provider Details

I. General information

NPI: 1164077608
Provider Name (Legal Business Name): MELISSA REVELEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E ST STE 2E
DAVIS CA
95616-4572
US

IV. Provider business mailing address

9113 SUTTON WAY
ORANGEVALE CA
95662-5241
US

V. Phone/Fax

Practice location:
  • Phone: 530-601-1003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: