Provider Demographics
NPI:1386776433
Name:RUBALCAVA, MELISSA (LPT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RUBALCAVA
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 W SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-558-4051
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD # 319
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-2382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32589164X00000X, 167G00000X
171M00000X
CAPT32589167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659419828Medicaid