Provider Demographics
NPI:1104522911
Name:GREEN MOUNTAIN PSYCHOTHERAPY PC
Entity type:Organization
Organization Name:GREEN MOUNTAIN PSYCHOTHERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLAGG
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:203-216-5641
Mailing Address - Street 1:223 MT PHILO RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FERRISBURGH
Mailing Address - State:VT
Mailing Address - Zip Code:05473-4015
Mailing Address - Country:US
Mailing Address - Phone:203-216-5641
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE RD STE 460A
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7780
Practice Address - Country:US
Practice Address - Phone:802-391-9137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health