Healthcare Provider Details

I. General information

NPI: 1497175459
Provider Name (Legal Business Name): TRAILSIDE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BRIDGE ST
SHELBURNE FALLS MA
01370-1142
US

IV. Provider business mailing address

111 BRIDGE ST
SHELBURNE FALLS MA
01370-1142
US

V. Phone/Fax

Practice location:
  • Phone: 413-625-6240
  • Fax: 413-625-6290
Mailing address:
  • Phone: 413-625-6240
  • Fax: 413-625-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1030561
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number213928
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209410
License Number StateMA

VIII. Authorized Official

Name: STEFAN A. TOPOLSKI
Title or Position: CEO
Credential: MD
Phone: 413-625-6240