Provider Demographics
NPI:1386777639
Name:COUNSELING CONNECTION TRAINING INSTITUTE, PLC
Entity type:Organization
Organization Name:COUNSELING CONNECTION TRAINING INSTITUTE, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEORA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:802-264-5333
Mailing Address - Street 1:525 HERCULES DR
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5993
Mailing Address - Country:US
Mailing Address - Phone:802-264-5333
Mailing Address - Fax:802-264-5338
Practice Address - Street 1:525 HERCULES DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5993
Practice Address - Country:US
Practice Address - Phone:802-264-5333
Practice Address - Fax:802-264-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011097Medicaid