MEDICARE: FULL CIRCLE HEALTH AND WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	048.0074506	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730461278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL CIRCLE HEALTH AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	73 MAIN ST
Second Line	:	SUITE 19
City	:	MONTPELIER
State	:	VT
Zip	:	05602-2932
Country	:	US
Telephone Number	:	802-505-1748
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 MAIN ST
Second Line	:	SUITE 19
City	:	MONTPELIER
State	:	VT
Zip	:	05602-2932
Country	:	US
Telephone Number	:	802-505-1748
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST-DOCTORATE
Name	:	DR. BROOKE WHITE
Credential	:	PHD
Telephone Number	:	802-505-1748

Provider Enumeration Date	:	09/11/2011
Last Update Date	:	09/11/2011

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