Healthcare Provider Details

I. General information

NPI: 1255536991
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: 03/24/2017
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 TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number649
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: STEVE MONETTE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 802-258-4312