Provider Demographics
NPI:1902326507
Name:VAN WAGENEN, MELISSA LEE (LMFTI)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEE
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:LMFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92152
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-2152
Mailing Address - Country:US
Mailing Address - Phone:818-720-9152
Mailing Address - Fax:
Practice Address - Street 1:643 BAIR ISLAND RD # 301
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2754
Practice Address - Country:US
Practice Address - Phone:650-424-0852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF96544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist