Healthcare Provider Details

I. General information

NPI: 1720618903
Provider Name (Legal Business Name): MELISSA RACHEL KAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 CASARIN AVE
SIMI VALLEY CA
93065-4515
US

IV. Provider business mailing address

20929 VENTURA BLVD # 47-170
WOODLAND HILLS CA
91364-2334
US

V. Phone/Fax

Practice location:
  • Phone: 805-539-3410
  • Fax:
Mailing address:
  • Phone: 805-539-3410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number89064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: