Provider Demographics
NPI:1629895081
Name:MELENDEZ, STAPHANY
Entity type:Individual
Prefix:
First Name:STAPHANY
Middle Name:
Last Name:MELENDEZ
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 1:1016 E BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4532
Mailing Address - Country:US
Mailing Address - Phone:800-371-1121
Mailing Address - Fax:
Practice Address - Street 1:1016 E BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4532
Practice Address - Country:US
Practice Address - Phone:800-371-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-75873103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst