MEDICARE: MELLISA GAIL DOUGLAS M.ED,LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	17005	TX
2	101Y00000X	Counselor	0701004135	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720194681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELLISA GAIL DOUGLAS M.ED,LPC

Provider Business Mailing Address
First Line	:	1302 BURNSVILLE RD
Second Line	:
City	:	WILLIAMSVILLE
State	:	VA
Zip	:	24487-2148
Country	:	US
Telephone Number	:	540-396-3379
Fax Number	:	540-886-7380

Provider Business Practice Location Address
First Line	:	71 WILSON BLVD STE A1
Second Line	:
City	:	FISHERSVILLE
State	:	VA
Zip	:	22939-2283
Country	:	US
Telephone Number	:	540-949-4202
Fax Number	:	540-886-7380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	12/02/2013

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