Healthcare Provider Details

I. General information

NPI: 1417995051
Provider Name (Legal Business Name): TINA L DESMARAIS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 02/24/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 GRAY RD
PLAINFIELD VT
05667-9050
US

IV. Provider business mailing address

879 GRAY RD
PLAINFIELD VT
05667-9050
US

V. Phone/Fax

Practice location:
  • Phone: 802-223-1177
  • Fax: 802-223-1177
Mailing address:
  • Phone: 802-223-1177
  • Fax: 802-223-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0000446
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000446
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: