Healthcare Provider Details

I. General information

NPI: 1457298192
Provider Name (Legal Business Name): BLUE RIDGE MIND AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 N SPRING DR
ROANOKE VA
24019-2545
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: 540-467-3199
Mailing address:
  • Phone: 540-467-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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