Healthcare Provider Details

I. General information

NPI: 1811388168
Provider Name (Legal Business Name): MELISIA SHANKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CYPRESS AVE
SOUTH SAN FRANCISCO CA
94080-2922
US

IV. Provider business mailing address

1969 TATE ST C204
EAST PALO ALTO CA
94303-2578
US

V. Phone/Fax

Practice location:
  • Phone: 650-817-9070
  • Fax:
Mailing address:
  • Phone: 650-817-9070
  • Fax: 650-246-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: