Provider Demographics
NPI:1992481568
Name:GREEN MOUNTAIN BEHAVIORAL MEDICINE LLC
Entity type:Organization
Organization Name:GREEN MOUNTAIN BEHAVIORAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUPP-STAR
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:802-230-1353
Mailing Address - Street 1:125 SAINT PAUL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-8686
Mailing Address - Country:US
Mailing Address - Phone:802-216-0727
Mailing Address - Fax:802-633-0956
Practice Address - Street 1:125 SAINT PAUL ST STE 103
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8686
Practice Address - Country:US
Practice Address - Phone:802-216-0727
Practice Address - Fax:802-633-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty