Individual
HEATHER TRAIL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
770 W RIDGE RD, WYTHEVILLE, VA 24382-1187
(276) 223-3200
(276) 223-0617
Mailing address
770 W RIDGE RD, WYTHEVILLE, VA 24382-1187
(276) 223-3200
(276) 223-0617
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
0701004655
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004945298
—
VA
01
—
1316271752
ANTHEM
—
01
—
430712
MHN TRICARE
VA
Enumeration date
10/01/2009
Last updated
06/20/2011
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