Provider Demographics
NPI:1194409243
Name:GREEN HERON PSYCHOTHERAPY PLLC
Entity type:Organization
Organization Name:GREEN HERON PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-432-8184
Mailing Address - Street 1:250 HALL CIR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05091-6022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 HALL CIR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VT
Practice Address - Zip Code:05091-6022
Practice Address - Country:US
Practice Address - Phone:802-432-8184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty