Healthcare Provider Details

I. General information

NPI: 1003233628
Provider Name (Legal Business Name): MELISSA ANN STAPLEFORD OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA KOENIG OTR/L

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

4668 PEMBROKE BLVD SUITE 115
VIRGINIA BEACH VA
23455-6423
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-4604
  • Fax: 757-467-2716
Mailing address:
  • Phone: 757-648-8561
  • Fax: 757-648-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number07346
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number07346
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number07346
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number07346
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119007025
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: