Provider Demographics
NPI:1053886937
Name:CORUM, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:CORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22199-0709
Mailing Address - Country:US
Mailing Address - Phone:703-957-8685
Mailing Address - Fax:
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5698
Practice Address - Country:US
Practice Address - Phone:703-330-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-006068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical