Healthcare Provider Details

I. General information

NPI: 1538585120
Provider Name (Legal Business Name): MELISSA JOANN BAGWELL WEEDING PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E SUITE #710
LOS ANGELES CA
90067-2001
US

IV. Provider business mailing address

1946 OVERLAND AVE APT 203
LOS ANGELES CA
90025-5852
US

V. Phone/Fax

Practice location:
  • Phone: 310-432-9374
  • Fax: 877-694-3331
Mailing address:
  • Phone: 310-633-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY27305
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: