Healthcare Provider Details

I. General information

NPI: 1689383754
Provider Name (Legal Business Name): BRYAN LINDBERG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S MAIN ST
GALAX VA
24333-3911
US

IV. Provider business mailing address

223 S MAIN ST
GALAX VA
24333-3911
US

V. Phone/Fax

Practice location:
  • Phone: 276-236-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRYAN LINDBERG
Title or Position: PROVIDER/OWNER
Credential:
Phone: 276-236-8888