Provider Demographics
NPI:1780690859
Name:STAVRAKIS, MELISSA JANE (DPT, OCS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:STAVRAKIS
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:BILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1605 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1081
Mailing Address - Country:US
Mailing Address - Phone:304-295-7290
Mailing Address - Fax:304-295-5922
Practice Address - Street 1:1605 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1081
Practice Address - Country:US
Practice Address - Phone:304-295-7290
Practice Address - Fax:304-295-5922
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7301143000Medicaid
P00148738OtherRAILROAD MEDICARE
OH2590290Medicaid
4111183Medicare PIN