Provider Demographics
NPI:1104170679
Name:ROANOKE RESOURCE LLC
Entity type:Organization
Organization Name:ROANOKE RESOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MCCAULEY-WITTL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP, PMHNP
Authorized Official - Phone:540-400-7431
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:540-400-7431
Mailing Address - Fax:540-400-7091
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:540-400-7431
Practice Address - Fax:540-400-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care