Provider Demographics
NPI:1225706195
Name:MYSTIC HORIZONS, LLC
Entity Type:Organization
Organization Name:MYSTIC HORIZONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-734-5864
Mailing Address - Street 1:4995 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:HINESBURG
Mailing Address - State:VT
Mailing Address - Zip Code:05461-9487
Mailing Address - Country:US
Mailing Address - Phone:802-734-5864
Mailing Address - Fax:
Practice Address - Street 1:4995 SILVER ST
Practice Address - Street 2:
Practice Address - City:HINESBURG
Practice Address - State:VT
Practice Address - Zip Code:05461-9487
Practice Address - Country:US
Practice Address - Phone:802-734-5864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty