Provider Demographics
NPI:1386909653
Name:FANG, MELANIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:FANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3100 MOWRY AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1509
Mailing Address - Country:US
Mailing Address - Phone:510-972-4673
Mailing Address - Fax:
Practice Address - Street 1:3100 MOWRY AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1509
Practice Address - Country:US
Practice Address - Phone:510-972-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2016-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist