Provider Demographics
NPI:1629513452
Name:BENNINGTON BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:BENNINGTON BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:THUNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:203-570-8778
Mailing Address - Street 1:326 ELM ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2211
Mailing Address - Country:US
Mailing Address - Phone:203-570-8778
Mailing Address - Fax:
Practice Address - Street 1:326 ELM ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2211
Practice Address - Country:US
Practice Address - Phone:203-570-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01119901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty