Provider Demographics
NPI:1679786131
Name:CROTCHED MOUNTAIN COMMUNITY CARE
Entity type:Organization
Organization Name:CROTCHED MOUNTAIN COMMUNITY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKULAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-831-8657
Mailing Address - Street 1:186 GRANITE ST STE 3C
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-2643
Mailing Address - Country:US
Mailing Address - Phone:603-668-7584
Mailing Address - Fax:603-431-5935
Practice Address - Street 1:186 GRANITE ST STE 3C
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-2643
Practice Address - Country:US
Practice Address - Phone:603-668-7584
Practice Address - Fax:603-431-5935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03262251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3079997Medicaid