Healthcare Provider Details

I. General information

NPI: 1376068148
Provider Name (Legal Business Name): MELISSA MAGALLANES PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2017
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 FOOTHILL BLVD STE B266
LA VERNE CA
91750-2901
US

IV. Provider business mailing address

2105 FOOTHILL BLVD STE B266
LA VERNE CA
91750-2901
US

V. Phone/Fax

Practice location:
  • Phone: 626-408-0919
  • Fax:
Mailing address:
  • Phone: 626-408-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY34292
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: