Provider Demographics
NPI:1538585120
Name:BAGWELL WEEDING, MELISSA JOANN (PSYD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOANN
Last Name:BAGWELL WEEDING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 OVERLAND AVE
Mailing Address - Street 2:APT 203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5852
Mailing Address - Country:US
Mailing Address - Phone:310-633-1812
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE #710
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-432-9374
Practice Address - Fax:877-694-3331
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
CAPSY27305103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic