Healthcare Provider Details

I. General information

NPI: 1760775571
Provider Name (Legal Business Name): ROBERT FREDERICK WUBBENHORST LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 FLAMSTEAD RD
CHESTER VT
05143-8893
US

IV. Provider business mailing address

246 FLAMSTEAD RD
CHESTER VT
05143-8893
US

V. Phone/Fax

Practice location:
  • Phone: 802-428-2008
  • Fax:
Mailing address:
  • Phone: 802-428-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0072017
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: