Provider Demographics
NPI:1649507682
Name:COLWELL, CHRISTINE A (LADC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:COLWELL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-0724
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:802-334-7455
Practice Address - Street 1:181 CRAWFORD ROAD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:VT
Practice Address - Zip Code:05829-0000
Practice Address - Country:US
Practice Address - Phone:802-334-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YA0400X
VT151.1035111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH81263824Medicaid