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General NPI Number Information
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NPI Number | 1053868976
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Entity Type | Organization
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Legal Business Name | GREEN MOUNTAIN PSYCHOLOGICAL ASSOCIATES, P.C.
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Dates
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Enumeration Date | 09/08/2016
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Last Update Date | 09/08/2016
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Provider Practice Location Address
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Address Line | 79 COURT ST
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City | MIDDLEBURY
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State | VT
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Zip | 05753-1406
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Country | US
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Telephone | 802-353-6580
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Fax |
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Provider Business Mailing Address
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Address Line | 93 COURT ST # A
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City | MIDDLEBURY
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State | VT
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Zip | 05753-4423
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Country | US
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Telephone | 802-353-6580
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DANIELLE RAE BERGERON INGRAM
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Credential | M.S.
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Telephone | 802-353-6580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0470111914
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License Number State | VT
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