Provider Demographics
NPI:1760472971
Name:BENNINGTON PROJECT INDEPENDENCE INC
Entity Type:Organization
Organization Name:BENNINGTON PROJECT INDEPENDENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WICHLAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-442-8136
Mailing Address - Street 1:124 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2523
Mailing Address - Country:US
Mailing Address - Phone:802-442-8136
Mailing Address - Fax:802-447-8291
Practice Address - Street 1:124 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2523
Practice Address - Country:US
Practice Address - Phone:802-442-8136
Practice Address - Fax:802-447-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT047W030Medicaid
VT047W129Medicaid