1780336990 NPI number — MS. VERA P MIKHAILOVA MS, LCMHC

Table of content: MS. VERA P MIKHAILOVA MS, LCMHC (NPI 1780336990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780336990 NPI number — MS. VERA P MIKHAILOVA MS, LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKHAILOVA
Provider First Name:
VERA
Provider Middle Name:
P
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780336990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 BROADLAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLCHESTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05446-6699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-363-9905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 HERCULES DR STE 1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLCHESTER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05446-8113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-391-4806
Provider Business Practice Location Address Fax Number:
802-264-5338
Provider Enumeration Date:
01/19/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  068.0134438 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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