Provider Demographics
NPI: | 1629591581 |
---|---|
Name: | BICKERSTAFF COUNSELING, LLC |
Entity Type: | Organization |
Organization Name: | BICKERSTAFF COUNSELING, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MEGHAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BICKERSTAFF |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCMHC |
Authorized Official - Phone: | 802-696-2485 |
Mailing Address - Street 1: | PO BOX 184 |
Mailing Address - Street 2: | |
Mailing Address - City: | MORRISVILLE |
Mailing Address - State: | VT |
Mailing Address - Zip Code: | 05661-0184 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 PARK ST |
Practice Address - Street 2: | |
Practice Address - City: | MORRISVILLE |
Practice Address - State: | VT |
Practice Address - Zip Code: | 05661-8659 |
Practice Address - Country: | US |
Practice Address - Phone: | 802-696-2485 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-07-24 |
Last Update Date: | 2017-07-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VT | 1024422 | Medicaid |