Healthcare Provider Details

I. General information

NPI: 1326105123
Provider Name (Legal Business Name): MARY ELLEN BUTTITTA LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S WINOOSKI AVE
BURLINGTON VT
05401-3830
US

IV. Provider business mailing address

102 S WINOOSKI AVE
BURLINGTON VT
05401-3830
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-1914
  • Fax: 802-660-3665
Mailing address:
  • Phone: 802-658-1914
  • Fax: 802-660-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000168
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: