Healthcare Provider Details

I. General information

NPI: 1992159107
Provider Name (Legal Business Name): PHILIP LYNN PEZESHKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 PATCHEN RD ASSOCIATES IN PSYCHOTHERAPY & FAMILY COUNSELING
SOUTH BURLINGTON VT
05403-5704
US

IV. Provider business mailing address

34 PATCHEN RD ASSOCIATES IN PSYCHOTHERAPY & FAMILY COUNSELING
SOUTH BURLINGTON VT
05403-5704
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-4208
  • Fax:
Mailing address:
  • Phone: 802-658-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0111996
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: