Healthcare Provider Details

I. General information

NPI: 1811025844
Provider Name (Legal Business Name): GEORGIANA BIRMINGHAM MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 ELM ST
MONTPELIER VT
05602-2995
US

IV. Provider business mailing address

PO BOX 627
MONTPELIER VT
05601-0627
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-9151
  • Fax: 802-229-2508
Mailing address:
  • Phone: 802-229-9151
  • Fax: 802-229-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0470000720
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: