Healthcare Provider Details

I. General information

NPI: 1205719994
Provider Name (Legal Business Name): HAYLEY PROFFITT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20822 RIVERSIDE DR
GRUNDY VA
24614-9597
US

IV. Provider business mailing address

20822 RIVERSIDE DR
GRUNDY VA
24614-9597
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone: 276-312-1563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701015128
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: