Basic Information
| Provider Information | |||||||||
| NPI: | 1306505359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY BY GERSH AT CROTCHED MOUNTAIN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEGACY BY GERSH AT CROTCHED MOUNTAIN, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
| FaxNumber: | 6035473232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
| FaxNumber: | 6035473232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2021 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5085239981 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 2084P0804X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 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 | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 363LP0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3132341 | 05 | NH | MEDICAID |