Healthcare Provider Details

I. General information

NPI: 1780130799
Provider Name (Legal Business Name): HOLLY L MELVIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

IV. Provider business mailing address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7000
  • Fax:
Mailing address:
  • Phone: 909-425-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: