Provider Demographics
NPI:1629632575
Name:ILLARIO, MELISSA TACY
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:TACY
Last Name:ILLARIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 N ANAHEIM BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-7567
Mailing Address - Country:US
Mailing Address - Phone:801-615-3160
Mailing Address - Fax:949-502-2802
Practice Address - Street 1:1044 N ANAHEIM BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-7567
Practice Address - Country:US
Practice Address - Phone:801-615-3160
Practice Address - Fax:949-502-2802
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical