Healthcare Provider Details

I. General information

NPI: 1679282073
Provider Name (Legal Business Name): RESTORATIVE MIND COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W STATE ST STE 302
BRISTOL VA
24201-3823
US

IV. Provider business mailing address

1009 W STATE ST STE 302
BRISTOL VA
24201-3823
US

V. Phone/Fax

Practice location:
  • Phone: 276-696-1799
  • Fax:
Mailing address:
  • Phone: 276-696-1799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTY WALKER
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC, NCC
Phone: 276-696-1799