Healthcare Provider Details

I. General information

NPI: 1124343801
Provider Name (Legal Business Name): MOUNTAIN LAUREL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14274 EGGBORNSVILLE RD
CULPEPER VA
22701-4844
US

IV. Provider business mailing address

10391 GREYSON LN
RIXEYVILLE VA
22737-1730
US

V. Phone/Fax

Practice location:
  • Phone: 540-829-1789
  • Fax: 540-829-0117
Mailing address:
  • Phone: 540-937-2334
  • Fax: 540-937-7680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number993-01019
License Number StateVA

VIII. Authorized Official

Name: BRUCE WYMAN
Title or Position: CEO-DIRECTOR OF PROGRAMS- OWNER
Credential: LPC, EDM
Phone: 540-937-2334