Provider Demographics
NPI:1255053930
Name:XANDER LODGE, MA, PLC
Entity type:Organization
Organization Name:XANDER LODGE, MA, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:LODGE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:802-503-2929
Mailing Address - Street 1:629 METCALF DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8802
Mailing Address - Country:US
Mailing Address - Phone:802-503-2929
Mailing Address - Fax:
Practice Address - Street 1:75 TALCOTT RD STE 30
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8122
Practice Address - Country:US
Practice Address - Phone:802-503-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-19
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty