Healthcare Provider Details

I. General information

NPI: 1396016150
Provider Name (Legal Business Name): KATIE RAE CHIVINGTON L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 MORRISTOWN CORNERS RD
MORRISVILLE VT
05661-8985
US

IV. Provider business mailing address

4705 VT ROUTE 100
HYDE PARK VT
05655-9613
US

V. Phone/Fax

Practice location:
  • Phone: 802-585-5510
  • Fax:
Mailing address:
  • Phone: 802-585-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number091.0073477
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: