Healthcare Provider Details

I. General information

NPI: 1053757930
Provider Name (Legal Business Name): MELISSA O'MARA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 GREAT BRIDGE BLVD STE A
CHESAPEAKE VA
23320-3904
US

IV. Provider business mailing address

224 GREAT BRIDGE BLVD
CHESAPEAKE VA
23320-3904
US

V. Phone/Fax

Practice location:
  • Phone: 757-819-6166
  • Fax: 757-819-6292
Mailing address:
  • Phone: 757-819-6166
  • Fax: 757-819-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701005461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: