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General NPI Number Information
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NPI Number | 1285479162
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Entity Type | Organization
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Legal Business Name | 15 EAST COLLECTIVE LLC
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Dates
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Enumeration Date | 07/01/2024
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 1225 VT-15
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City | WOLCOTT
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State | VT
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Zip | 05680
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Country | US
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Telephone | 802-323-8392
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Fax |
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Provider Business Mailing Address
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Address Line | 1225 VT 15
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City | WOLCOTT
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State | VT
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Zip | 05680-3034
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Country | US
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Telephone | 802-323-8392
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST MASTERS LEVEL
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Name | DARRIN GREENE
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Credential | LPM, LADC
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Telephone | 802-323-1236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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