=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700648425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERMONT MENTAL HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 ALLEN BROOK LN
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05495-9201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-881-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1735 QUAKER ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05443-9276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-881-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAWN MAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 802-881-2452
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------