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General NPI Number Information
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NPI Number | 1629792114
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Entity Type | Organization
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Legal Business Name | NORTHEAST KINGDOM TRAUMA INTENSIVES
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Dates
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Enumeration Date | 09/28/2022
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Last Update Date | 09/28/2022
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Provider Practice Location Address
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Address Line | 293 PEARL ST STE 101
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City | ST JOHNSBURY
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State | VT
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Zip | 05819-5641
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Country | US
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Telephone | 802-327-5902
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Fax |
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Provider Business Mailing Address
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Address Line | 751 CHESTERFIELD HOLW
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City | LYNDONVILLE
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State | VT
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Zip | 05851-8530
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Country | US
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Telephone | 540-797-5703
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Fax |
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Authorized Official
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Title or Position | OWNER/PSYCHOTHERAPIST
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Name | DR. JENNIFER LYNN KEITH
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Credential | PHD, LPC, LCHMC, NCC
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Telephone | 802-327-5902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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