MEDICARE: MINDFUL MOUNTAIN WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	101YM0800X	Mental Health Counselor
3	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1083453161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL MOUNTAIN WELLNESS CENTER

Provider Business Mailing Address
First Line	:	4734 HICKORY HILL DR
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-7430
Country	:	US
Telephone Number	:	210-315-5629
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 CHAPARRAL DR STE 109C
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-4355
Country	:	US
Telephone Number	:	540-792-3872
Fax Number	:	540-767-6555

Authorized Official
Title or Position	:	PSYCHIATRIST
Name	:	DR. RYAN MATTHEW WHITE
Credential	:	DO
Telephone Number	:	210-315-5629

Provider Enumeration Date	:	05/20/2024
Last Update Date	:	01/02/2026

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