Healthcare Provider Details

I. General information

NPI: 1104170679
Provider Name (Legal Business Name): ROANOKE RESOURCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 CAMPBELL AVE SW
ROANOKE VA
24016-3627
US

IV. Provider business mailing address

402 CAMPBELL AVE SW
ROANOKE VA
24016-3627
US

V. Phone/Fax

Practice location:
  • Phone: 540-400-7431
  • Fax: 540-400-7091
Mailing address:
  • Phone: 540-400-7431
  • Fax: 540-400-7091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CELIA LEA MCCAULEY-WITTL
Title or Position: OPERATIONS COORDINATOR
Credential: DNP, FNP, PMHNP
Phone: 540-400-7431