Healthcare Provider Details

I. General information

NPI: 1265933915
Provider Name (Legal Business Name): MELISSA KHABBAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 CAMINO DEL RIO S STE 101
SAN DIEGO CA
92108-4100
US

IV. Provider business mailing address

1333 S MAYFLOWER AVE STE 220
MONROVIA CA
91016-5239
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6780
  • Fax: 800-819-7806
Mailing address:
  • Phone: 818-241-6780
  • Fax: 800-819-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-50489
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: