Provider Demographics
NPI:1356579775
Name:TWIN STATE PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:TWIN STATE PSYCHOLOGICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:II
Authorized Official - Credentials:EDD
Authorized Official - Phone:802-885-5719
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2003
Mailing Address - Country:US
Mailing Address - Phone:802-885-5719
Mailing Address - Fax:802-885-5720
Practice Address - Street 1:29 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3060
Practice Address - Country:US
Practice Address - Phone:802-885-5719
Practice Address - Fax:802-885-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1016751Medicaid
NH3080088Medicaid
VT0026543Medicare PIN
VT1016751Medicaid
NH002654301Medicare PIN