Healthcare Provider Details

I. General information

NPI: 1629792114
Provider Name (Legal Business Name): NORTHEAST KINGDOM TRAUMA INTENSIVES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 PEARL ST STE 101
ST JOHNSBURY VT
05819-5641
US

IV. Provider business mailing address

751 CHESTERFIELD HOLW
LYNDONVILLE VT
05851-8530
US

V. Phone/Fax

Practice location:
  • Phone: 802-327-5902
  • Fax:
Mailing address:
  • Phone: 540-797-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER LYNN KEITH
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: PHD, LPC, LCHMC, NCC
Phone: 802-327-5902