Provider Demographics
NPI:1083997563
Name:FORENSIC CONSULTATION & COUNSELING SERVICE
Entity Type:Organization
Organization Name:FORENSIC CONSULTATION & COUNSELING SERVICE
Other - Org Name:FORENSIC CONSULTATION & COUNSELING SERVICE, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS LADC AFC
Authorized Official - Phone:802-772-0700
Mailing Address - Street 1:135 GRANGER ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4405
Mailing Address - Country:US
Mailing Address - Phone:802-772-0700
Mailing Address - Fax:802-771-8009
Practice Address - Street 1:135 GRANGER ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4405
Practice Address - Country:US
Practice Address - Phone:802-772-0700
Practice Address - Fax:802-771-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000447101YA0400X, 101YP2500X
VT068.0047526101YM0800X
101YM0800X, 1041C0700X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019731Medicaid