Provider Demographics
NPI:1992853436
Name:MOUNTAIN LAUREL GROUP LLC
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC,NCC,EDM
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:2007-01-08
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA993-14-001322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children