Basic Information
| Provider Information | |||||||||
| NPI: | 1740282276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRABACH | ||||||||
| FirstName: | ELEANOR | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHEELER | ||||||||
| OtherFirstName: | ELEANOR | ||||||||
| OtherMiddleName: | TERESA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 STRATTON RD | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028552027 | ||||||||
| FaxNumber: | 8028552053 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 STRATTON RD | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027733386 | ||||||||
| FaxNumber: | 8027734578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW5774 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 1624 | NH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 089-0105654 | VT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 04183006 | 05 | NY | MEDICAID | 1024723 | 05 | VT | MEDICAID |