Healthcare Provider Details

I. General information

NPI: 1316271752
Provider Name (Legal Business Name): HEATHER TRAIL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 W RIDGE RD
WYTHEVILLE VA
24382-1187
US

IV. Provider business mailing address

770 W RIDGE RD
WYTHEVILLE VA
24382-1187
US

V. Phone/Fax

Practice location:
  • Phone: 276-223-3200
  • Fax: 276-223-0617
Mailing address:
  • Phone: 276-223-3200
  • Fax: 276-223-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701004655
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: