Healthcare Provider Details

I. General information

NPI: 1093382616
Provider Name (Legal Business Name): META ELIZA SURJAPUTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3634
  • Fax: 802-847-8961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048.0135289
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: