Healthcare Provider Details

I. General information

NPI: 1275438517
Provider Name (Legal Business Name): MATTHEW DAVID STEFANOWICZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 STRATTON RD
RUTLAND VT
05701-4619
US

IV. Provider business mailing address

223 ADAMS ST
RUTLAND VT
05701-2302
US

V. Phone/Fax

Practice location:
  • Phone: 802-772-7071
  • Fax:
Mailing address:
  • Phone: 860-690-6877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1035732
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: