Provider Demographics
NPI:1386264265
Name:GUERETTA, MELISSA (ATC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GUERETTA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2943 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-4590
Mailing Address - Country:US
Mailing Address - Phone:707-217-0207
Mailing Address - Fax:
Practice Address - Street 1:1250 HAHMAN DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6996
Practice Address - Country:US
Practice Address - Phone:707-890-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer