Healthcare Provider Details

I. General information

NPI: 1073631149
Provider Name (Legal Business Name): MELISSA OLSON BLACK M.S., A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 RIVER ROAD WEST
GOOCHLAND VA
23063
US

IV. Provider business mailing address

5004 TORI LN
GOOCHLAND VA
23063-2115
US

V. Phone/Fax

Practice location:
  • Phone: 804-556-5322
  • Fax:
Mailing address:
  • Phone: 804-306-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000030
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: