1134842909 NPI number — DRIFT MAVYN LICSW LLC

Table of content: (NPI 1134842909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134842909 NPI number — DRIFT MAVYN LICSW LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRIFT MAVYN LICSW LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134842909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWNSHEND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05353-0157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-321-5066
Provider Business Mailing Address Fax Number:
802-210-3972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74 GRAFTON RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWNSHEND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-321-5066
Provider Business Practice Location Address Fax Number:
802-210-3972
Provider Enumeration Date:
09/26/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MAVYN
Authorized Official First Name:
DRIFT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
802-321-5066

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MVP0551 . This is a "MVP INSURANCE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 5212947 . This is a "BCBS VERMONT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 6712069 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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