Organization
MOUNTAIN LAUREL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRUCE C WYMAN LPC,NCC,EDM (DIRECTOR/CEO)
(540) 829-1789
Entity
Organization
Contact information
Practice address
102 N MAIN ST STE 300, CULPEPER, VA 22701-3053
(540) 829-1789
(540) 829-0117
Mailing address
102 N MAIN ST STE 300, CULPEPER, VA 22701-3053
(540) 829-1789
(540) 829-0117
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
993-14-001
VA
Other
Enumeration date
01/08/2007
Last updated
01/26/2012
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