Provider Demographics
NPI:1245361096
Name:GREEN MOUNTAIN PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:GREEN MOUNTAIN PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOULE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, PRESIDENT
Authorized Official - Phone:603-298-5595
Mailing Address - Street 1:103 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-1618
Mailing Address - Country:US
Mailing Address - Phone:603-298-5595
Mailing Address - Fax:603-298-5205
Practice Address - Street 1:103 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-1618
Practice Address - Country:US
Practice Address - Phone:603-298-5595
Practice Address - Fax:603-298-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE5499Medicare UPIN