Healthcare Provider Details

I. General information

NPI: 1952817868
Provider Name (Legal Business Name): TOM HARRISON LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANNA MARSH LANE
BRATTLEBORO VT
05302-0101
US

IV. Provider business mailing address

1 ANNA MARSH LANE
BRATTLEBORO VT
05302-0101
US

V. Phone/Fax

Practice location:
  • Phone: 802-257-7785
  • Fax: 802-258-3798
Mailing address:
  • Phone: 802-257-7785
  • Fax: 802-258-3798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0126411
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: