=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366713349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA BERTL L.AC.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2012
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46169 WESTLAKE DR SUITE 300
-----------------------------------------------------
City | STERLING
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20165-5875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-421-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 S ARLINGTON RIDGE RD #701
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22202-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-650-7643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 0121000653
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------