Provider Demographics
NPI:1164394177
Name:BLUE RIDGE INTEGRATIVE WELLNESS LLC
Entity type:Organization
Organization Name:BLUE RIDGE INTEGRATIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LPC
Authorized Official - Phone:941-391-7261
Mailing Address - Street 1:512 DRYDEN LOOP
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:VA
Mailing Address - Zip Code:24243
Mailing Address - Country:US
Mailing Address - Phone:941-391-7261
Mailing Address - Fax:
Practice Address - Street 1:512 DRYDEN LOOP
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:VA
Practice Address - Zip Code:24243
Practice Address - Country:US
Practice Address - Phone:941-391-7261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty