Healthcare Provider Details

I. General information

NPI: 1992818439
Provider Name (Legal Business Name): DEER CREEK PSYCHOLOGICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LYME RD SUITE 202A
HANOVER NH
03755-1219
US

IV. Provider business mailing address

PO BOX 266
EAST THETFORD VT
05043-0266
US

V. Phone/Fax

Practice location:
  • Phone: 802-785-2543
  • Fax: 802-785-2631
Mailing address:
  • Phone: 802-785-2903
  • Fax: 802-785-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND J. CHIN
Title or Position: PRESIDENT
Credential: PHD
Phone: 603-643-9252