Basic Information
| Provider Information | |||||||||
| NPI: | 1891721262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROTCHED MOUNTAIN REHABILITATION CENTER, INC. | ||||||||
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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: | 06/25/2006 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6035473311 | ||||||||
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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 | NH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 2084P0804X | N | 193200000X MULTI-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 | 225800000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation 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 | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 50Y519400NH01 | 01 | NH | BC PROFESSIONAL GROUP # | OTHER | 0000005NA | 01 | NH | ANTHEM BC FACILITY # | OTHER | 1020140 | 05 | VT | MEDICAID | 3076358 | 05 | NH | MEDICAID |