Healthcare Provider Details

I. General information

NPI: 1053293803
Provider Name (Legal Business Name): SIERRA PEMBROKE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUMMER ST
BARRE VT
05641-3741
US

IV. Provider business mailing address

PO BOX 647
MONTPELIER VT
05601-0647
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-4055
  • Fax: 802-661-5699
Mailing address:
  • Phone: 802-479-4055
  • Fax: 802-661-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0137112
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number097.0134963
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: