Healthcare Provider Details

I. General information

NPI: 1760818595
Provider Name (Legal Business Name): BLUE MOUNTAIN THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17507 LEE HWY
ABINGDON VA
24210-7835
US

IV. Provider business mailing address

17507 LEE HWY
ABINGDON VA
24210-7835
US

V. Phone/Fax

Practice location:
  • Phone: 276-525-6043
  • Fax: 888-233-7885
Mailing address:
  • Phone: 276-525-6043
  • Fax: 888-233-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH CLINT WADDELL
Title or Position: ADMINISTRATION
Credential:
Phone: 276-525-6043