Basic Information
| Provider Information | |||||||||
| NPI: | 1497206585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOMBERGER | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX G | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050600167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITALITY DRIVE | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022234156 | ||||||||
| FaxNumber: | 8022234332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 151.0124410 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.