Healthcare Provider Details

I. General information

NPI: 1386709905
Provider Name (Legal Business Name): VIRGIL JOHN KOVACHICH II MA,LADC,LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SCHOOL STREET SUITE D
BARTON VT
05822-0156
US

IV. Provider business mailing address

PO BOX 156
BARTON VT
05822-0156
US

V. Phone/Fax

Practice location:
  • Phone: 802-525-4529
  • Fax:
Mailing address:
  • Phone: 802-525-4529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000135
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000570
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: