Healthcare Provider Details

I. General information

NPI: 1679873137
Provider Name (Legal Business Name): MELINDA SALLIS MFT-INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 W CHEYENNE AVE
NORTH LAS VEGAS NV
89032-2484
US

IV. Provider business mailing address

1512 DESTINY RIDGE CT
HENDERSON NV
89074-2948
US

V. Phone/Fax

Practice location:
  • Phone: 702-675-6314
  • Fax: 702-476-9697
Mailing address:
  • Phone: 702-478-0271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMI4227
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMI0828
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMI4227
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI0828
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI4227
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMI0828
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: