Healthcare Provider Details

I. General information

NPI: 1356548499
Provider Name (Legal Business Name): AMENA MACSHEA LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 DENSMORE HILL
HARTLAND FOUR CORNERS VT
05049
US

IV. Provider business mailing address

PO BOX 74
HARTLAND FOUR CORNERS VT
05049-0074
US

V. Phone/Fax

Practice location:
  • Phone: 802-436-2133
  • Fax:
Mailing address:
  • Phone: 802-436-2133
  • Fax: 802-436-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000711
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: