Healthcare Provider Details

I. General information

NPI: 1427110188
Provider Name (Legal Business Name): TINA L BLEAU M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 AIRPORT RD
S BURLINGTON VT
05403-6432
US

IV. Provider business mailing address

11 TAFT ST
ESSEX JUNCTION VT
05452-3150
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-3924
  • Fax: 802-658-0216
Mailing address:
  • Phone: 802-288-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number047-0000688
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: