Healthcare Provider Details

I. General information

NPI: 1649644782
Provider Name (Legal Business Name): EXPERIENTIAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2015
Last Update Date: 11/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 CAMPBELL RD
MORRISTOWN VT
05661-4481
US

IV. Provider business mailing address

1089 CAMPBELL RD
MORRISTOWN VT
05661-4481
US

V. Phone/Fax

Practice location:
  • Phone: 802-355-5550
  • Fax: 802-888-2244
Mailing address:
  • Phone: 802-355-5550
  • Fax: 802-888-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0680066612
License Number StateVT

VIII. Authorized Official

Name: MR. ANTHONY DOMINIC DEPAUL
Title or Position: COUNSELOR/OWNER
Credential: LCMHC
Phone: 802-355-5550