Healthcare Provider Details

I. General information

NPI: 1114872314
Provider Name (Legal Business Name): WHITLEY GABRIELLE WAGNER LMHP-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 STEELSBURG HWY STE 10
CEDAR BLUFF VA
24609-7056
US

IV. Provider business mailing address

PO BOX 435
CEDAR BLUFF VA
24609-0435
US

V. Phone/Fax

Practice location:
  • Phone: 276-963-2363
  • Fax: 276-963-2360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0704017605
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: