Provider Demographics
NPI:1417282112
Name:SMITH, MELISSA CAVANAUGH (MSPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAVANAUGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7151 RICHMOND RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7234
Mailing Address - Country:US
Mailing Address - Phone:757-565-5400
Mailing Address - Fax:757-565-3560
Practice Address - Street 1:7151 RICHMOND RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7234
Practice Address - Country:US
Practice Address - Phone:757-565-5400
Practice Address - Fax:757-565-3560
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305006441OtherSTATE LICENSE