Provider Demographics
NPI:1730185232
Name:BRATTLEBORO RETREAT
Entity type:Organization
Organization Name:BRATTLEBORO RETREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-258-4310
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0101
Mailing Address - Country:US
Mailing Address - Phone:802-257-7785
Mailing Address - Fax:802-258-3798
Practice Address - Street 1:22 ANNA MARSH LANE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05302-0803
Practice Address - Country:US
Practice Address - Phone:802-257-7785
Practice Address - Fax:802-258-3723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0855X, 261QM0801X, 261QM0850X, 261QM1300X, 3336C0002X, 3336I0012X
VT649283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0474001Medicaid
VTVT4001Medicare PIN
VT0474001Medicaid
VT474001Medicare Oscar/Certification
VTVN0203Medicare PIN