Provider Demographics
NPI:1548587405
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/ DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDM,NCC,LPC
Authorized Official - Phone:540-829-1789
Mailing Address - Street 1:102 N MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3053
Mailing Address - Country:US
Mailing Address - Phone:540-829-1789
Mailing Address - Fax:540-829-0117
Practice Address - Street 1:102 N MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3053
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:2010-04-30
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003919101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty