Healthcare Provider Details

I. General information

NPI: 1508862392
Provider Name (Legal Business Name): BLUE RIDGE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2005
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-6200
US

IV. Provider business mailing address

170 THOMAS JOHNSON DR STE 200
FREDERICK MD
21702-6200
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-8390
  • Fax: 301-694-7906
Mailing address:
  • Phone: 301-695-8390
  • Fax: 301-694-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LAURIE M. LEPEONKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-695-8390