Healthcare Provider Details

I. General information

NPI: 1336767755
Provider Name (Legal Business Name): GREEN MOUNTAIN PSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 UNION STREET THE GRANARY, FIRST FLOOR
BRANDON VT
05733
US

IV. Provider business mailing address

8 CASE ST
BRANDON VT
05733-1169
US

V. Phone/Fax

Practice location:
  • Phone: 802-989-1274
  • Fax:
Mailing address:
  • Phone: 802-989-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH DC TAYLOR
Title or Position: OWNER PSYCHOLOGIST
Credential: MS
Phone: 802-989-1274