Basic Information
| Provider Information | |||||||||
| NPI: | 1548715154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOMBLE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8501 ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039706458 | ||||||||
| FaxNumber: | 7039706465 | ||||||||
| Practice Location | |||||||||
| Address1: | 8501 ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039706458 | ||||||||
| FaxNumber: | 7039706465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2016 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 0810005316 | VA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.