Provider Demographics
NPI:1366713349
Name:BERTL, MELISSA (LAC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BERTL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S ARLINGTON RIDGE RD
Mailing Address - Street 2:#701
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-1952
Mailing Address - Country:US
Mailing Address - Phone:941-650-7643
Mailing Address - Fax:
Practice Address - Street 1:46169 WESTLAKE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5875
Practice Address - Country:US
Practice Address - Phone:703-421-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000653171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist