=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255265666
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVATE A WELLNESS PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2026
-----------------------------------------------------
Last Update Date | 06/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4436 COSTELLO WAY SUITE 301 A
-----------------------------------------------------
City | HAYMARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-248-1138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13221 FLYNN CT
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-1775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-248-1138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER BAXTER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 870-316-1638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------