Provider Demographics
NPI:1104239474
Name:BLUE RIDGE COUNSELING
Entity type:Organization
Organization Name:BLUE RIDGE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCAS
Authorized Official - Phone:336-677-3991
Mailing Address - Street 1:PO BOX 1758
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-1758
Mailing Address - Country:US
Mailing Address - Phone:336-677-3991
Mailing Address - Fax:336-677-1359
Practice Address - Street 1:110 W ELM ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-8203
Practice Address - Country:US
Practice Address - Phone:336-677-3991
Practice Address - Fax:336-677-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223101YA0400X
NC1070101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty