Healthcare Provider Details

I. General information

NPI: 1992477848
Provider Name (Legal Business Name): MELODY AGBISIT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELODY MORENO MA

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 PRINCESS ANNE RD
VIRGINIA BEACH VA
23462-6464
US

IV. Provider business mailing address

249 W FREEMASON ST APT 304
NORFOLK VA
23510-1353
US

V. Phone/Fax

Practice location:
  • Phone: 757-332-2122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number701011259
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: