Healthcare Provider Details

I. General information

NPI: 1609900141
Provider Name (Legal Business Name): ELIZABETH GRACE FLYNN CAMPBELL LIC. PSYCHOANALYST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 S UNION ST
BURLINGTON VT
05401-4859
US

IV. Provider business mailing address

444 S UNION ST
BURLINGTON VT
05401-4859
US

V. Phone/Fax

Practice location:
  • Phone: 802-860-2244
  • Fax:
Mailing address:
  • Phone: 802-860-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000035-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: