Provider Demographics
NPI:1609622067
Name:POWERBACK PEDIATRICS OF VERMONT, LLC
Entity type:Organization
Organization Name:POWERBACK PEDIATRICS OF VERMONT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP OF PEDIATRICS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-672-2593
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:888-269-9876
Mailing Address - Fax:
Practice Address - Street 1:861 WILLISTON RD STE 8
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5724
Practice Address - Country:US
Practice Address - Phone:888-269-9876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty