Healthcare Provider Details

I. General information

NPI: 1043765712
Provider Name (Legal Business Name): MELISSA DIEHL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 OLD HOWELL RD
GREENVILLE SC
29615-1969
US

IV. Provider business mailing address

2140 BIERCE DR
VIRGINIA BEACH VA
23454-7217
US

V. Phone/Fax

Practice location:
  • Phone: 877-508-3237
  • Fax:
Mailing address:
  • Phone: 757-675-0588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number2305005563
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: