Healthcare Provider Details

I. General information

NPI: 1396602793
Provider Name (Legal Business Name): ADDICTION WELLNESS CENTER VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 JOHN MARSHALL HWY STE 203
FRONT ROYAL VA
22630-3744
US

IV. Provider business mailing address

1100 BUSINESS PKWY S STE 1
WESTMINSTER MD
21157-3048
US

V. Phone/Fax

Practice location:
  • Phone: 540-655-2936
  • Fax: 540-736-4371
Mailing address:
  • Phone: 540-655-2936
  • Fax: 540-736-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 540-655-2936