Healthcare Provider Details

I. General information

NPI: 1235076852
Provider Name (Legal Business Name): BLUE RIDGE MIND AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 N SPRING DR
ROANOKE VA
24019
US

IV. Provider business mailing address

115 ROANOKE BLVD # 5016
SALEM VA
24153-4907
US

V. Phone/Fax

Practice location:
  • Phone: 540-467-3199
  • Fax:
Mailing address:
  • Phone: 540-467-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELLE WHITTAKER
Title or Position: NURSE PRACTITIONER
Credential: DNP PMHNP-BC FNP-BC
Phone: 540-467-3199