Provider Demographics
NPI:1013417914
Name:DISTANCETHERAPY.COM
Entity Type:Organization
Organization Name:DISTANCETHERAPY.COM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:802-448-3954
Mailing Address - Street 1:130 MANSFIELD AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3396
Mailing Address - Country:US
Mailing Address - Phone:802-448-3954
Mailing Address - Fax:
Practice Address - Street 1:130 MANSFIELD AVE APT 201
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3396
Practice Address - Country:US
Practice Address - Phone:802-448-3954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0102645101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty