Healthcare Provider Details

I. General information

NPI: 1265311740
Provider Name (Legal Business Name): MATEO ELLERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 FARMVU DR
WHITE RIVER JUNCTION VT
05001-6001
US

IV. Provider business mailing address

92 FARMVU DR
WHITE RIVER JUNCTION VT
05001-6001
US

V. Phone/Fax

Practice location:
  • Phone: 802-698-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number147.0123023
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: