Provider Demographics
| NPI: | 1063501476 |
|---|---|
| Name: | NORTHWESTERN COUNSELING & SUPPORT SERVICES INC |
| Entity type: | Organization |
| Organization Name: | NORTHWESTERN COUNSELING & SUPPORT SERVICES INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | TED |
| Authorized Official - Middle Name: | JOHN |
| Authorized Official - Last Name: | MABLE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | EDD |
| Authorized Official - Phone: | 802-524-6555 |
| Mailing Address - Street 1: | 107 FISHER POND RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SAINT ALBANS |
| Mailing Address - State: | VT |
| Mailing Address - Zip Code: | 05478-6286 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 802-524-6554 |
| Mailing Address - Fax: | 802-524-6562 |
| Practice Address - Street 1: | 107 FISHER POND RD |
| Practice Address - Street 2: | |
| Practice Address - City: | SAINT ALBANS |
| Practice Address - State: | VT |
| Practice Address - Zip Code: | 05478-6286 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 802-524-6554 |
| Practice Address - Fax: | 802-524-6562 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-10-12 |
| Last Update Date: | 2015-09-10 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 251S00000X | Agencies | Community/Behavioral Health | |
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
| No | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities | |
| No | 251K00000X | Agencies | Public Health or Welfare |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| VT | 1006428 | Medicaid | |
| VT | 491116 | Other | VALUE OPTIONS |
| VT | 1006107 | Medicaid | |
| VT | 1006629 | Medicaid | |
| VT | 355023 | Other | MHN |
| VT | FRAN6103 | Other | BCBS |
| VT | 0006103 | Medicaid | |
| VT | 1009767 | Medicaid | |
| VT | 1009766 | Medicaid | |
| VT | 2050939 | Other | CIGNA |
| VT | 1007307 | Medicaid | |
| VT | CN7031 | Other | RR MEDICARE |
| VT | 66316 | Other | MVP |
| VT | 1001094 | Medicaid | |
| VT | 1009766 | Medicaid |
