Healthcare Provider Details

I. General information

NPI: 1114166568
Provider Name (Legal Business Name): MELANIE GREENBERG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HIGH BLUFF DR STE 111
SAN DIEGO CA
92130-2053
US

IV. Provider business mailing address

8500 OLD STONEFIELD CHASE
SAN DIEGO CA
92127-6150
US

V. Phone/Fax

Practice location:
  • Phone: 415-742-8062
  • Fax: 415-742-8062
Mailing address:
  • Phone: 415-742-8062
  • Fax: 415-742-8062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY22075
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY22075
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: