Healthcare Provider Details

I. General information

NPI: 1962166322
Provider Name (Legal Business Name): CASEY GOLDMAN, LCMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OLDE ORCHARD PARK APT 641
SOUTH BURLINGTON VT
05403-6971
US

IV. Provider business mailing address

489 ETHAN ALLEN PKWY
BURLINGTON VT
05408-1002
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-0001
  • Fax:
Mailing address:
  • Phone: 802-363-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CASEY GOLDMAN
Title or Position: PROVIDER
Credential: LCMHC
Phone: 802-363-0001