Healthcare Provider Details

I. General information

NPI: 1992152276
Provider Name (Legal Business Name): GREEN MOUNTAIN COUNSELING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 MAIN ST SUITE 207-D
BRATTLEBORO VT
05301-7128
US

IV. Provider business mailing address

167 MAIN ST SUITE 207-D
BRATTLEBORO VT
05301-7128
US

V. Phone/Fax

Practice location:
  • Phone: 413-345-8745
  • Fax: 877-532-0268
Mailing address:
  • Phone: 413-345-8745
  • Fax: 877-532-0268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0067951
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0000688
License Number StateVT

VIII. Authorized Official

Name: THEODORE E WALLS
Title or Position: OWNER
Credential: LCMHC
Phone: 413-345-8745