Provider Demographics
NPI:1285479162
Name:15 EAST COLLECTIVE LLC
Entity type:Organization
Organization Name:15 EAST COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST MASTERS LEVEL
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:LPM, LADC
Authorized Official - Phone:802-323-1236
Mailing Address - Street 1:1225 VT 15
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:VT
Mailing Address - Zip Code:05680-3034
Mailing Address - Country:US
Mailing Address - Phone:802-323-8392
Mailing Address - Fax:
Practice Address - Street 1:1225 VT-15
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:VT
Practice Address - Zip Code:05680
Practice Address - Country:US
Practice Address - Phone:802-323-8392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty