Provider Demographics
NPI:1104272343
Name:NORTHEAST KINGDOM COUNCIL ON AGING
Entity type:Organization
Organization Name:NORTHEAST KINGDOM COUNCIL ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CASE MANAGEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH ROUSSEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-5182
Mailing Address - Street 1:481 SUMMER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-2103
Mailing Address - Country:US
Mailing Address - Phone:802-748-5182
Mailing Address - Fax:802-748-6622
Practice Address - Street 1:481 SUMMER ST STE 101
Practice Address - Street 2:
Practice Address - City:SAINT JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2103
Practice Address - Country:US
Practice Address - Phone:802-748-5182
Practice Address - Fax:802-748-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT047W003Medicaid