Provider Demographics
NPI:1407197031
Name:STOLLER, GREGG (MSW, BCB A)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:STOLLER
Suffix:
Gender:M
Credentials:MSW, BCB A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6102
Practice Address - Country:US
Practice Address - Phone:802-258-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1-12-12266103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst