Healthcare Provider Details

I. General information

NPI: 1013425560
Provider Name (Legal Business Name): SIR PRELL GROSS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BRAMBLETON AVE STE 201A
ROANOKE VA
24018-6527
US

IV. Provider business mailing address

3433 BRAMBLETON AVE STE 201A
ROANOKE VA
24018-6527
US

V. Phone/Fax

Practice location:
  • Phone: 540-266-7550
  • Fax: 540-266-7230
Mailing address:
  • Phone: 540-266-7550
  • Fax: 540-266-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007314
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: