Provider Demographics
NPI:1134465784
Name:47 MAIN STREET CORPORATION
Entity Type:Organization
Organization Name:47 MAIN STREET CORPORATION
Other - Org Name:FORTYSEVEN MAIN STREET, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLEM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:802-468-5325
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:706 MAIN STREET
Mailing Address - City:CASTLETON
Mailing Address - State:VT
Mailing Address - Zip Code:05735-0038
Mailing Address - Country:US
Mailing Address - Phone:800-287-5325
Mailing Address - Fax:802-468-5152
Practice Address - Street 1:706 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:VT
Practice Address - Zip Code:05735-0038
Practice Address - Country:US
Practice Address - Phone:800-287-5325
Practice Address - Fax:802-468-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness