Provider Demographics
NPI:1346510609
Name:MOUNTAIN LAUREL GROUP, LLC
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:540-829-1789
Mailing Address - Street 1:102 N MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3064
Mailing Address - Country:US
Mailing Address - Phone:540-829-1789
Mailing Address - Fax:540-829-0117
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3064
Practice Address - Country:US
Practice Address - Phone:540-829-1789
Practice Address - Fax:540-829-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA993-03-001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health