Provider Demographics
NPI:1366002636
Name:BRATTLEBORO RETREAT
Entity Type:Organization
Organization Name:BRATTLEBORO RETREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-258-6885
Mailing Address - Street 1:24 LINDEN STREET
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302
Mailing Address - Country:US
Mailing Address - Phone:802-257-7785
Mailing Address - Fax:
Practice Address - Street 1:24 LINDEN STREET
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05302
Practice Address - Country:US
Practice Address - Phone:802-257-7785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1004215Medicaid