Provider Demographics
NPI:1841969094
Name:CENTER FOR TRAUMA RECOVERY LLC
Entity type:Organization
Organization Name:CENTER FOR TRAUMA RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORBALLY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-281-3330
Mailing Address - Street 1:523 SMUGGLERS VIEW RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05464-9450
Mailing Address - Country:US
Mailing Address - Phone:802-324-3792
Mailing Address - Fax:
Practice Address - Street 1:523 SMUGGLERS VIEW RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05464-9450
Practice Address - Country:US
Practice Address - Phone:802-324-3792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1028428Medicaid