Healthcare Provider Details

I. General information

NPI: 1215811922
Provider Name (Legal Business Name): NORTHEAST KINGDOM HUMAN SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 CRAWFORD RD
DERBY VT
05829
US

IV. Provider business mailing address

PO BOX 724
NEWPORT VT
05855-0724
US

V. Phone/Fax

Practice location:
  • Phone: 802-334-6744
  • Fax:
Mailing address:
  • Phone: 802-337-6744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANITA HODGEMAN
Title or Position: BILLING MANAGER
Credential:
Phone: 802-334-7451