Provider Demographics
NPI:1619916905
Name:GONZAGA, MELANIE RECEL (DPT)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:RECEL
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15442 EAGLE TAVERN LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-3717
Mailing Address - Country:US
Mailing Address - Phone:703-587-0261
Mailing Address - Fax:703-443-6702
Practice Address - Street 1:11800 SUNRISE VALLEY DR STE 1
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5302
Practice Address - Country:US
Practice Address - Phone:703-709-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052033492251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008177L89Medicare ID - Type UnspecifiedMEDICARE ID NUMBER