Healthcare Provider Details

I. General information

NPI: 1538607239
Provider Name (Legal Business Name): CORTNEY AMBER DONOHUE SLOBODNJAK LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MAIN ST.
CHESTER VT
05143
US

IV. Provider business mailing address

PO BOX 346
CHESTER VT
05143-0346
US

V. Phone/Fax

Practice location:
  • Phone: 802-558-1989
  • Fax:
Mailing address:
  • Phone: 802-558-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0112799
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number068.0112799
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number068.0112799
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: