Healthcare Provider Details

I. General information

NPI: 1174209241
Provider Name (Legal Business Name): MELISSA K DYER COUNSELOR 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1166 MANSFIELD CT
TRACY CA
95376-8612
US

IV. Provider business mailing address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

V. Phone/Fax

Practice location:
  • Phone: 209-219-8011
  • Fax:
Mailing address:
  • Phone: 209-468-6857
  • Fax: 209-468-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1456000122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: