Healthcare Provider Details

I. General information

NPI: 1093628018
Provider Name (Legal Business Name): MALLORY LAURYN RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 S MAIN ST
BARRE VT
05641-4871
US

IV. Provider business mailing address

18 S MAIN ST
BARRE VT
05641-4871
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-7373
  • Fax:
Mailing address:
  • Phone: 802-479-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number194.0000032
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: