Provider Demographics
NPI:1497206585
Name:BOMBERGER, GLENN (LADC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BOMBERGER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX G
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-0167
Mailing Address - Country:US
Mailing Address - Phone:802-728-4466
Mailing Address - Fax:802-728-4197
Practice Address - Street 1:100 HOSPITALITY DRIVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05641
Practice Address - Country:US
Practice Address - Phone:802-223-4156
Practice Address - Fax:802-223-4332
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0124410101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)