Healthcare Provider Details

I. General information

NPI: 1750570719
Provider Name (Legal Business Name): ERICA FAYRIE LCMHC, LMHC, ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S MAIN ST STE 8
RANDOLPH VT
05060-1367
US

IV. Provider business mailing address

PO BOX 512
BROOKFIELD VT
05036-0512
US

V. Phone/Fax

Practice location:
  • Phone: 802-552-8604
  • Fax:
Mailing address:
  • Phone: 802-552-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number068.0134143
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6164
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: