Healthcare Provider Details

I. General information

NPI: 1013301324
Provider Name (Legal Business Name): MARY JEAN SADLAK PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 BENMONT AVE SUITE 20
BENNINGTON VT
05201-1873
US

IV. Provider business mailing address

160 BENMONT AVE SUITE 20
BENNINGTON VT
05201-1873
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-3520
  • Fax: 802-447-3392
Mailing address:
  • Phone: 802-442-3520
  • Fax: 802-447-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048.0000505
License Number StateVT

VIII. Authorized Official

Name: MARY JEAN SADLAK
Title or Position: OWNER
Credential: PHD
Phone: 802-442-3520