Provider Demographics
NPI:1861691826
Name:MOUNTCASTLE, LORETTA V (LCSW)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:V
Last Name:MOUNTCASTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-0213
Mailing Address - Country:US
Mailing Address - Phone:804-769-3022
Mailing Address - Fax:804-769-1253
Practice Address - Street 1:11814 KING WILLIAM RD
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-4103
Practice Address - Country:US
Practice Address - Phone:804-769-3022
Practice Address - Fax:804-769-1253
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040011741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007639406Medicaid