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General NPI Number Information
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NPI Number | 1801383807
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Entity Type | Organization
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Legal Business Name | MARANATHA MISSION HOME NETWORK, INC
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Dates
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Enumeration Date | 04/16/2018
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Last Update Date | 04/16/2018
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Provider Practice Location Address
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Address Line | 2580 COUNTY HIGHWAY 11
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City | HARTWICK
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State | NY
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Zip | 13348-2101
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Country | US
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Telephone | 802-848-9455
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 97
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City | RICHFORD
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State | VT
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Zip | 05476-0097
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KRISTIN SHEPERD
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Credential | LADC
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Telephone | 802-848-9455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 151.0126020
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License Number State | VT
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