Basic Information
| Provider Information | |||||||||
| NPI: | 1104497767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY BY GERSH AT CROTCHED MOUNTAIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
| FaxNumber: | 6035472072 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
| FaxNumber: | 6035472072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5085239981 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | School | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 320600000X | N | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities | 322D00000X | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.