Provider Demographics
NPI:1699899187
Name:NORTHWESTERN COUNSELING & SUPPORT SERVICES
Entity type:Organization
Organization Name:NORTHWESTERN COUNSELING & SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MABLE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:802-524-6555
Mailing Address - Street 1:107 FISHER POND ROAD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-6286
Mailing Address - Country:US
Mailing Address - Phone:802-524-6554
Mailing Address - Fax:802-524-6562
Practice Address - Street 1:107 FISHER POND ROAD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-6286
Practice Address - Country:US
Practice Address - Phone:802-524-6554
Practice Address - Fax:802-524-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTCN7031OtherRR MEDICARE
VT355023OtherMHN
VT66316OtherMVP
VT491116OtherVALUE OPTIONS
VT1008203Medicaid
VTFRAN6103OtherBCBS
VT2050939OtherCIGNA
VT2050939OtherCIGNA