Provider Demographics
NPI:1588347421
Name:STATE STREET TMS
Entity type:Organization
Organization Name:STATE STREET TMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JADA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KHOSLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-213-1005
Mailing Address - Street 1:147 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-3301
Mailing Address - Country:US
Mailing Address - Phone:802-321-3692
Mailing Address - Fax:
Practice Address - Street 1:147 STATE ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3301
Practice Address - Country:US
Practice Address - Phone:802-321-3692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-08
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty