Provider Demographics
NPI:1750596441
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:MR
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:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-0507
Mailing Address - Country:US
Mailing Address - Phone:540-829-1789
Mailing Address - Fax:540-825-4617
Practice Address - Street 1:16126 BRANDY RD
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4622
Practice Address - Country:US
Practice Address - Phone:540-829-1789
Practice Address - Fax:540-825-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children