Provider Demographics
NPI:1316904360
Name:MAPLE LEAF FARM ASSOCIATES, INC.
Entity type:Organization
Organization Name:MAPLE LEAF FARM ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO & EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:IACUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LADC, CCS
Authorized Official - Phone:802-899-2911
Mailing Address - Street 1:786 COLLEGE PARKWAY
Mailing Address - Street 2:MAPLE LEAF TREATMENT CENTER
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-899-2911
Mailing Address - Fax:802-899-2327
Practice Address - Street 1:10 MAPLE LEAF FARM RD
Practice Address - Street 2:MAPLE LEAF TREATMENT CENTER
Practice Address - City:UNDERHILL
Practice Address - State:VT
Practice Address - Zip Code:05489
Practice Address - Country:US
Practice Address - Phone:802-899-2911
Practice Address - Fax:802-899-2327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0401X
VT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0000304Medicaid