Provider Demographics
NPI:1144075623
Name:CONOLLY, MELINDA WONG (PSYD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:WONG
Last Name:CONOLLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FAY AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4324
Mailing Address - Country:US
Mailing Address - Phone:415-971-1820
Mailing Address - Fax:
Practice Address - Street 1:7777 FAY AVE STE 205
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4324
Practice Address - Country:US
Practice Address - Phone:415-971-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36184103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program