Healthcare Provider Details

I. General information

NPI: 1083584254
Provider Name (Legal Business Name): MELANIE SELOMI DEVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLOMA WAY STE C
ROSEVILLE CA
95661-4480
US

IV. Provider business mailing address

1133 COLOMA WAY STE C
ROSEVILLE CA
95661-4480
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-6647
  • Fax: 916-774-6456
Mailing address:
  • Phone: 916-774-6647
  • Fax: 916-774-6456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLR10550625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: