Provider Demographics
NPI:1144053430
Name:CHAMPLAIN CENTER FOR PLAY THERAPY AND FAMILY COUNSELING
Entity type:Organization
Organization Name:CHAMPLAIN CENTER FOR PLAY THERAPY AND FAMILY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGAO MARCOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-222-6247
Mailing Address - Street 1:145 PINE HAVEN SHORES RD STE 100A
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7703
Mailing Address - Country:US
Mailing Address - Phone:802-222-6247
Mailing Address - Fax:
Practice Address - Street 1:300 CORNERSTONE DR STE 320
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4012
Practice Address - Country:US
Practice Address - Phone:802-222-6247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)