Provider Demographics
NPI:1417447723
Name:PRIDE SUPPORT SERVICES INC
Entity Type:Organization
Organization Name:PRIDE SUPPORT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-279-1736
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0969
Mailing Address - Country:US
Mailing Address - Phone:802-479-5801
Mailing Address - Fax:
Practice Address - Street 1:36 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-3773
Practice Address - Country:US
Practice Address - Phone:802-479-5801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009952Medicaid
VT047W288Medicaid
VT1010068Medicaid