Healthcare Provider Details

I. General information

NPI: 1518788686
Provider Name (Legal Business Name): BLUE RIDGE MENTAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 BREVARD RD #216
HORSE SHOE NC
28742-1137
US

IV. Provider business mailing address

3740 BREVARD RD #216
HORSE SHOE NC
28742-1137
US

V. Phone/Fax

Practice location:
  • Phone: 336-515-1193
  • Fax:
Mailing address:
  • Phone: 336-515-1193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. CECILIA P FAUST
Title or Position: CLINICAL OUTREACH MANAGER, CO-OWNER
Credential: MD
Phone: 336-515-1193