Healthcare Provider Details

I. General information

NPI: 1649030990
Provider Name (Legal Business Name): OWL CREEK COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9023 FOREST HILL AVE STE 2A
NORTH CHESTERFIELD VA
23235-3054
US

IV. Provider business mailing address

3819 E WEYBURN RD
RICHMOND VA
23235-2037
US

V. Phone/Fax

Practice location:
  • Phone: 804-255-9341
  • Fax:
Mailing address:
  • Phone: 607-262-0458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: VICTOR BUCKLEW
Title or Position: CEO
Credential:
Phone: 804-255-9538