Healthcare Provider Details

I. General information

NPI: 1073487708
Provider Name (Legal Business Name): MOUNTAIN RIDGE COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 TOWNCENTER DR UNIT 1698
CLEMMONS NC
27012
US

IV. Provider business mailing address

PO BOX 114
STATE ROAD NC
28676-0114
US

V. Phone/Fax

Practice location:
  • Phone: 336-569-4340
  • Fax:
Mailing address:
  • Phone: 336-569-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MELISSA CASSTEVENS
Title or Position: OWNER/PROVIDER/AUTHORIZED REP
Credential:
Phone: 336-466-7268