Provider Demographics
NPI:1386169027
Name:CLARK, MELINDA ANNE
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANNE
Last Name:CLARK
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 1:1370 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-7803
Mailing Address - Country:US
Mailing Address - Phone:530-891-0973
Mailing Address - Fax:
Practice Address - Street 1:1370 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-7803
Practice Address - Country:US
Practice Address - Phone:530-891-0973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129557106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA76-0802338Medicaid