Active NPI
Melissa Diane Boudin, PSY.D.
- Clinical Psychologist
- Pacoima, CA
National Provider Identifier
1053752634
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY26430
- Practice address
- 12450 Van Nuys Blvd
Suite 200
Pacoima, CA 91331-1391 - Phone
- (818) 896-1161
- Fax
- (818) 896-5069
- NPI assigned
- Jul 11, 2013
- Last updated
- Feb 15, 2017
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY26430 | CA | Primary |
Addresses
Primary practice location
12450 Van Nuys Blvd
Suite 200
Pacoima, CA 91331-1391
Mailing address
12450 Van Nuys Blvd
Suite 200
Pacoima, CA 91331-1391
Phone (818) 896-1161
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7068 | Medicaid | CA | |
| 7420 | Medicaid | CA | |
| 6758 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY26430 | CA | MD | Clinical Psychologist |
| 26430 | CA | MD | Massage Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Psychotherapy and Mental Wellness Group Practice, PLLC | Current | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Brooklyn, NY
- NPI 1669043196
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1373500800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1487116800000",
"number": "1053752634",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12450 VAN NUYS BLVD",
"address_2": "SUITE 200",
"city": "PACOIMA",
"state": "CA",
"postal_code": "913311391",
"telephone_number": "818-896-1161",
"fax_number": "818-896-5069"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12450 VAN NUYS BLVD",
"address_2": "SUITE 200",
"city": "PACOIMA",
"state": "CA",
"postal_code": "913311391",
"telephone_number": "818-896-1161",
"fax_number": "818-896-5069"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUDIN",
"first_name": "MELISSA",
"middle_name": "DIANE",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2013-07-11",
"last_updated": "2017-02-15",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY26430",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "7068",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "7420",
"state": "CA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6758",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Pacoima, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.