Basic Information
| Provider Information | |||||||||
| NPI: | 1386710861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARA MARTIN CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX G | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | GIDNEY | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR. QUALITY ASSURANCE | ||||||||
| AuthorizedOfficialTelephone: | 8027284466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QP0905X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1003145 | 05 | VT | MEDICAID | T000381 | 01 | VT | TRICARE | OTHER | VT6178 | 01 | VT | BLUE CROSS | OTHER | 63909C | 01 | VT | MVP | OTHER | 93909A | 01 | VT | MVP | OTHER | 93909 | 01 | VT | MVP | OTHER | 1007256 | 05 | VT | MEDICAID | 1009814 | 05 | VT | MEDICAID | 1027774 | 01 | VT | CIGNA | OTHER | 00800321 | 01 | VT | BLUE CROSS | OTHER | 1009815 | 05 | VT | MEDICAID | 63909A | 01 | VT | MVP | OTHER | 00006178 | 05 | VT | MEDICAID | 1006421 | 05 | VT | MEDICAID | 50Y083800VT01 | 01 | VT | ANTHEM | OTHER | 63909 | 01 | VT | MVP | OTHER | 93909C | 01 | VT | MVP | OTHER |