Healthcare Provider Details

I. General information

NPI: 1164857272
Provider Name (Legal Business Name): MELISSA C KEYLOR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HOPE ROAD SUITE 213
STAFFORD VA
22554
US

IV. Provider business mailing address

8140 ASHTON AVE 200
MANASSAS VA
20109-5698
US

V. Phone/Fax

Practice location:
  • Phone: 540-658-0855
  • Fax: 703-368-8454
Mailing address:
  • Phone: 703-330-9933
  • Fax: 703-368-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710101862
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005458
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: