MEDICARE: CROSS KEYS EQUINE THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1760828545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSS KEYS EQUINE THERAPY

Provider Business Mailing Address
First Line	:	6107 HORSE FARM LN
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2634
Country	:	US
Telephone Number	:	540-607-6910
Fax Number	:

Provider Business Practice Location Address
First Line	:	6107 HORSE FARM LN
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2634
Country	:	US
Telephone Number	:	540-607-6910
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH COUNSELOR
Name	:	AUSTIN CANALE MIKOLIN
Credential	:	LPC
Telephone Number	:	540-280-0243

Provider Enumeration Date	:	05/20/2013
Last Update Date	:	09/22/2021

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