Healthcare Provider Details

I. General information

NPI: 1376672402
Provider Name (Legal Business Name): COUNSELING SERVICE OF ADDISON COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 MAIN ST
MIDDLEBURY VT
05753-1459
US

IV. Provider business mailing address

89 MAIN ST
MIDDLEBURY VT
05753-1459
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-6751
  • Fax: 802-388-8183
Mailing address:
  • Phone: 802-388-6751
  • Fax: 802-388-8183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT JIMERSON
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 802-388-6751