Provider Demographics
NPI:1720194681
Name:DOUGLAS, MELLISA GAIL (MED,LPC)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:GAIL
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BURNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24487-2148
Mailing Address - Country:US
Mailing Address - Phone:540-396-3379
Mailing Address - Fax:540-886-7380
Practice Address - Street 1:71 WILSON BLVD STE A1
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2283
Practice Address - Country:US
Practice Address - Phone:540-949-4202
Practice Address - Fax:540-886-7380
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17005101YP2500X
VA0701004135101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162090801Medicaid