Provider Demographics
NPI:1528124021
Name:TUCKER, MELANIE MARILYN
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MARILYN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, MA, LMFT
Mailing Address - Street 1:18075 VENTURA BOULEVARD
Mailing Address - Street 2:SUITE 132
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3517
Mailing Address - Country:US
Mailing Address - Phone:818-996-5358
Mailing Address - Fax:
Practice Address - Street 1:18075 VENTURA BLVD
Practice Address - Street 2:SUITE 132
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3517
Practice Address - Country:US
Practice Address - Phone:818-996-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24174106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist