Healthcare Provider Details

I. General information

NPI: 1669492518
Provider Name (Legal Business Name): CHERYL M MULLOOLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 BUSH RIVER DR
FARMVILLE VA
23901
US

IV. Provider business mailing address

P.O. DRAWER 248
FARMVILLE VA
23901
US

V. Phone/Fax

Practice location:
  • Phone: 434-392-3187
  • Fax: 434-392-9221
Mailing address:
  • Phone: 434-392-7049
  • Fax: 434-392-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701003753
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: