Healthcare Provider Details

I. General information

NPI: 1932551991
Provider Name (Legal Business Name): GREEN MOUNTAIN EMDR AND PSYCHOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 BENMONT AVE STE 20
BENNINGTON VT
05201-1842
US

IV. Provider business mailing address

PO BOX 846
BENNINGTON VT
05201-0846
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-3520
  • Fax:
Mailing address:
  • Phone: 802-442-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: HEIDI PETERSON
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 802-442-3520