Healthcare Provider Details

I. General information

NPI: 1073261517
Provider Name (Legal Business Name): NATHAN RAILLA LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 EASTERN AVE STE 205
ST JOHNSBURY VT
05819-5600
US

IV. Provider business mailing address

190 EASTERN AVE STE 205
ST JOHNSBURY VT
05819-5600
US

V. Phone/Fax

Practice location:
  • Phone: 303-667-9060
  • Fax:
Mailing address:
  • Phone: 303-667-9060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0134331
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: