Provider Demographics
NPI:1295557155
Name:MYERS, MELISSA GENON (LCSW)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:GENON
Last Name:MYERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 15TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4102
Mailing Address - Country:US
Mailing Address - Phone:951-236-0491
Mailing Address - Fax:
Practice Address - Street 1:5887 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1853
Practice Address - Country:US
Practice Address - Phone:951-275-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty