Healthcare Provider Details

I. General information

NPI: 1093877300
Provider Name (Legal Business Name): SUSIE ELIZABETH CARON M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SWAMP RD
FAIRFAX VT
05454-9777
US

IV. Provider business mailing address

PO BOX 275
FAIRFAX VT
05454-0275
US

V. Phone/Fax

Practice location:
  • Phone: 802-849-2777
  • Fax:
Mailing address:
  • Phone: 802-849-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number047-0000717
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: