=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285404400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINDHAM WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2024
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 MAIN ST STE 207E
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-266-4983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 167 MAIN ST STE 207E
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-266-4983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST; CLINICAL SUPERVISOR
-----------------------------------------------------
Name | MR. DAVID ALLEN BINGHAM JR.
-----------------------------------------------------
Credential | LCMHC, NCC, ACS
-----------------------------------------------------
Telephone | 802-266-4983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------