Provider Demographics
NPI:1073631149
Name:BLACK, MELISSA OLSON (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:OLSON
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 TORI LN
Mailing Address - Street 2:
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-2115
Mailing Address - Country:US
Mailing Address - Phone:804-306-4268
Mailing Address - Fax:
Practice Address - Street 1:3250 RIVER ROAD WEST
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063
Practice Address - Country:US
Practice Address - Phone:804-556-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260000302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer