Provider Demographics
NPI:1831839604
Name:MIND GARDEN ROANOKE PLLC
Entity type:Organization
Organization Name:MIND GARDEN ROANOKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCAULEY-WITTL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:540-765-8696
Mailing Address - Street 1:402 CAMPBELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-3627
Mailing Address - Country:US
Mailing Address - Phone:540-765-8696
Mailing Address - Fax:
Practice Address - Street 1:402 CAMPBELL AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-3627
Practice Address - Country:US
Practice Address - Phone:540-765-8696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty