Healthcare Provider Details

I. General information

NPI: 1669369948
Provider Name (Legal Business Name): MELISSA J DIOSES PORLLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10565 FAIRFAX BLVD STE 300
FAIRFAX VA
22030-3104
US

IV. Provider business mailing address

8312 KINGSGATE RD APT D
SPRINGFIELD VA
22152-1187
US

V. Phone/Fax

Practice location:
  • Phone: 703-218-6599
  • Fax:
Mailing address:
  • Phone: 703-269-7978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-313861
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: