Provider Demographics
NPI:1801383807
Name:MARANATHA MISSION HOME NETWORK, INC
Entity Type:Organization
Organization Name:MARANATHA MISSION HOME NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPERD
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:802-848-9455
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:RICHFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05476-0097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2580 COUNTY HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:HARTWICK
Practice Address - State:NY
Practice Address - Zip Code:13348-2101
Practice Address - Country:US
Practice Address - Phone:802-848-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0126020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT14143916OtherCAQH