Healthcare Provider Details

I. General information

NPI: 1922684257
Provider Name (Legal Business Name): EVAN MATTHEW OPPENHEIMER LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 MAIN ST
WAITSFIELD VT
05673-6003
US

IV. Provider business mailing address

515 E WARREN RD
WAITSFIELD VT
05673-7310
US

V. Phone/Fax

Practice location:
  • Phone: 802-583-1144
  • Fax:
Mailing address:
  • Phone: 516-359-0292
  • 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:
Title or Position:
Credential:
Phone: