Healthcare Provider Details

I. General information

NPI: 1255421004
Provider Name (Legal Business Name): ELIZAVETA MATIACH MS, LPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WASHINGTON HWY
MORRISVILLE VT
05661-8652
US

IV. Provider business mailing address

PO BOX 749
MORRISVILLE VT
05661-0749
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-8320
  • Fax: 802-888-8136
Mailing address:
  • Phone: 802-851-8619
  • Fax: 802-851-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0127410
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number047-0000698
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number047.0000698
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: