Healthcare Provider Details

I. General information

NPI: 1104034529
Provider Name (Legal Business Name): PSYCHOTHERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MAHONEY AVE
RUTLAND VT
05701
US

IV. Provider business mailing address

90 MAHONEY AVE
RUTLAND VT
05701
US

V. Phone/Fax

Practice location:
  • Phone: 802-775-2581
  • Fax: 802-775-3395
Mailing address:
  • Phone: 802-775-2581
  • Fax: 802-775-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0680000177
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5324
License Number StateVT

VIII. Authorized Official

Name: ALBON J COGHLON
Title or Position: OWNER
Credential: MD
Phone: 802-775-2581