Healthcare Provider Details

I. General information

NPI: 1154281004
Provider Name (Legal Business Name): STACEY D LARIVIERE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 N MAIN ST
RUTLAND VT
05701-2412
US

IV. Provider business mailing address

71 ALLEN ST STE 101
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-772-7992
  • Fax:
Mailing address:
  • Phone: 802-779-9036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number060577-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: