Provider Demographics
NPI:1891346433
Name:GANDARA, MELIZA MARIA (LCSW)
Entity type:Individual
Prefix:
First Name:MELIZA
Middle Name:MARIA
Last Name:GANDARA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2722
Mailing Address - Country:US
Mailing Address - Phone:909-623-6131
Mailing Address - Fax:
Practice Address - Street 1:5000 BIRCH ST STE 3000
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2140
Practice Address - Country:US
Practice Address - Phone:877-421-1711
Practice Address - Fax:949-576-3913
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126259101YM0800X, 1041C0700X
390200000X
CA95914101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program