1356579775 NPI number — TWIN STATE PSYCHOLOGICAL SERVICES

Table of content: (NPI 1356579775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356579775 NPI number — TWIN STATE PSYCHOLOGICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN STATE PSYCHOLOGICAL SERVICES
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:
6
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:
1356579775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05156-2003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-885-5719
Provider Business Mailing Address Fax Number:
802-885-5720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 RIDGEWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05156-3060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-885-5719
Provider Business Practice Location Address Fax Number:
802-885-5720
Provider Enumeration Date:
06/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROOT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
802-885-5719

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1016751 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3080088 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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