Provider Demographics
NPI:1164627808
Name:BRATTLEBORO RETREAT
Entity Type:Organization
Organization Name:BRATTLEBORO RETREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-258-4392
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0101
Mailing Address - Country:US
Mailing Address - Phone:802-257-7785
Mailing Address - Fax:802-258-3798
Practice Address - Street 1:ANNA MARSH LANE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-257-7785
Practice Address - Fax:802-258-3798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT649283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007212Medicaid