Healthcare Provider Details

I. General information

NPI: 1770665812
Provider Name (Legal Business Name): BEATRICE ANN MELLUSI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 KEARNY VILLA RD SUITE 116
SAN DIEGO CA
92123-1578
US

IV. Provider business mailing address

3635 CEDARBRAE LN
SAN DIEGO CA
92106-3255
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone: 619-223-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: