Healthcare Provider Details

I. General information

NPI: 1952312373
Provider Name (Legal Business Name): GARY WAYNE WATULAK M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 COTTAGE ST
RUTLAND VT
05701-3404
US

IV. Provider business mailing address

26 COTTAGE ST
RUTLAND VT
05701-3404
US

V. Phone/Fax

Practice location:
  • Phone: 802-775-6031
  • Fax: 802-775-6031
Mailing address:
  • Phone: 802-775-6031
  • Fax: 802-775-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0470000240
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0470000240
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0470000240
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0470000240
License Number StateVT
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number0470000240
License Number StateVT
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number0470000240
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: