Provider Demographics
NPI:1699241349
Name:WALLACE, MELANIE L (AMFT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:L
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT
Mailing Address - Street 1:2629 FOOTHILL BLVD # 298
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3511
Mailing Address - Country:US
Mailing Address - Phone:818-308-4346
Mailing Address - Fax:
Practice Address - Street 1:9713 SANTA MONICA BLVD STE 207
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4243
Practice Address - Country:US
Practice Address - Phone:818-308-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-21
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109773106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist