Provider Demographics
NPI:1245782556
Name:LUCK, MELANIE RAE (ATC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:RAE
Last Name:LUCK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 COMPTON VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-5702
Mailing Address - Country:US
Mailing Address - Phone:703-424-1423
Mailing Address - Fax:
Practice Address - Street 1:14311 COMPTON VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5702
Practice Address - Country:US
Practice Address - Phone:703-424-1423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20000246982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAR50971758OtherBLUE CROSS BLUE SHIELD