Healthcare Provider Details

I. General information

NPI: 1447032115
Provider Name (Legal Business Name): SHELBURNE MIND BODY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FERRY RD
CHARLOTTE VT
05445-9901
US

IV. Provider business mailing address

PO BOX 42
CHARLOTTE VT
05445-0042
US

V. Phone/Fax

Practice location:
  • Phone: 802-448-4408
  • Fax: 802-341-6595
Mailing address:
  • Phone: 802-448-4408
  • Fax: 802-341-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DARCY NORA FAIBISH
Title or Position: CLINICAL DIRECTOR
Credential: NP
Phone: 802-448-4408