Healthcare Provider Details

I. General information

NPI: 1861700510
Provider Name (Legal Business Name): MELISSA FOWLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA ELIZABETH BARTLOTTI LCSW

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15651 IMPERIAL HWY SUITE 203
LA MIRADA CA
90638-1628
US

IV. Provider business mailing address

PO BOX 1831
LA MIRADA CA
90637-1831
US

V. Phone/Fax

Practice location:
  • Phone: 562-383-1728
  • Fax: 562-309-8319
Mailing address:
  • Phone: 562-383-1728
  • Fax: 562-309-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33406
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: