Healthcare Provider Details

I. General information

NPI: 1164627808
Provider Name (Legal Business Name): BRATTLEBORO RETREAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ANNA MARSH LANE
BRATTLEBORO VT
05301
US

IV. Provider business mailing address

PO BOX 101
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 Code283Q00000X
TaxonomyPsychiatric Hospital
License Number649
License Number StateVT

VIII. Authorized Official

Name: JENNIFER BROUSSARD
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 802-258-4392