Provider Demographics
NPI:1194190421
Name:FAMA, RACHEL MELISSA (PTA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:MELISSA
Last Name:FAMA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MELISSA
Other - Last Name:HOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:11657 CHARTER OAK CT APT 201
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4531
Mailing Address - Country:US
Mailing Address - Phone:585-944-0228
Mailing Address - Fax:
Practice Address - Street 1:1936 OPITZ BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3360
Practice Address - Country:US
Practice Address - Phone:540-841-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605075225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194190421Medicaid