Healthcare Provider Details

I. General information

NPI: 1013211481
Provider Name (Legal Business Name): JEFFREY W LOURIE FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2010
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAIN ST STE 201
MONTPELIER VT
05602-4257
US

IV. Provider business mailing address

250 MAIN ST STE 201
MONTPELIER VT
05602-4257
US

V. Phone/Fax

Practice location:
  • Phone: 802-828-1234
  • Fax: 802-828-1221
Mailing address:
  • Phone: 802-828-1234
  • Fax: 802-828-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0095764
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP101078
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR055703
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0097231
License Number StateVT
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0095764
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: