Healthcare Provider Details

I. General information

NPI: 1265079842
Provider Name (Legal Business Name): IMAGINE & CREATE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 WESTERN AVE
BRATTLEBORO VT
05301-6589
US

IV. Provider business mailing address

229 WESTERN AVE
BRATTLEBORO VT
05301-6589
US

V. Phone/Fax

Practice location:
  • Phone: 802-536-4067
  • Fax: 802-327-8327
Mailing address:
  • Phone: 802-536-4067
  • Fax: 802-327-8327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTI BECK
Title or Position: OWNER/ THERAPIST
Credential: LICSW
Phone: 802-536-4067