MEDICARE: MS. MELISSA FAY GONDEK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PSY23451	CA
2	103TB0200X	Cognitive & Behavioral Psychologist	PSY23451	CA
3	103TP2701X	Group Psychotherapy Psychologist	PSY23451	CA
4	103TF0000X	Family Psychologist	PSY23451	CA

General Provider Information

NPI Number	:	1144413477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELISSA FAY GONDEK PHD

Provider Business Mailing Address
First Line	:	4055 E THOUSAND OAKS BLVD
Second Line	:	SUITE 215
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-3600
Country	:	US
Telephone Number	:	805-795-1238
Fax Number	:

Provider Business Practice Location Address
First Line	:	4055 E THOUSAND OAKS BLVD
Second Line	:	SUITE 215
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91362-3600
Country	:	US
Telephone Number	:	805-795-1238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	06/24/2010

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