Provider Demographics
NPI:1881192300
Name:MCCANN, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:MCCANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 WATER OAK RD APT 511
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2015
Mailing Address - Country:US
Mailing Address - Phone:315-941-3992
Mailing Address - Fax:
Practice Address - Street 1:4016 RAINTREE RD STE 100A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:757-488-4735
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007571225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316051287Medicaid