Healthcare Provider Details

I. General information

NPI: 1902113285
Provider Name (Legal Business Name): PATRICIA L MARSHALL MS, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 MAIN STREET #4
HYDE PARK VT
05655
US

IV. Provider business mailing address

PO BOX 334 179 MAIN STREET #4
HYDE PARK VT
05655
US

V. Phone/Fax

Practice location:
  • Phone: 802-279-1631
  • Fax: 802-851-1141
Mailing address:
  • Phone: 802-279-1631
  • Fax: 802-851-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number000499
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000499
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: