Healthcare Provider Details

I. General information

NPI: 1629091707
Provider Name (Legal Business Name): BENJAMIN D. SKOLNIK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 DORSET ST SUITE 10
SOUTH BURLINGTON VT
05403-6209
US

IV. Provider business mailing address

366 DORSET ST SUITE 10
SOUTH BURLINGTON VT
05403-6209
US

V. Phone/Fax

Practice location:
  • Phone: 802-654-7607
  • Fax: 802-654-9155
Mailing address:
  • Phone: 802-654-7607
  • Fax: 802-654-9155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number047-0000724
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: