| Phoenix Psychotherapy Llc | |
|
595 Dorset St Ste 2 South Burlington VT 05403-6240 | |
| (802) 651-8999 | |
| (802) 651-8997 |
| Full Name | Phoenix Psychotherapy Llc |
|---|---|
| Speciality | Psychologist |
| Location | 595 Dorset St Ste 2, South Burlington, Vermont |
| Authorized Official Name and Position | Judith Vanderryn (OWNER/SOLE PROPRIETOR) |
| Authorized Official Contact | 8026518999 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Phoenix Psychotherapy Llc Po Box 125 Vergennes VT 05491-0125 Ph: (802) 651-8999 | Phoenix Psychotherapy Llc 595 Dorset St Ste 2 South Burlington VT 05403-6240 Ph: (802) 651-8999 |
| NPI Number | 1114348166 |
|---|---|
| Provider Enumeration Date | 12/18/2013 |
| Last Update Date | 12/18/2023 |
| Certification Date | 12/18/2023 |
| Medicare PECOS PAC ID | 5597996488 |
|---|---|
| Medicare Enrollment ID | O20240118001436 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114348166 | NPI | - | NPPES |
| 1760587323 | Other | CO | INDIVIDUAL NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | 2051 (Colorado) | Primary |
| Provider Name | Judith Henriette Vanderryn |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1760587323 PECOS PAC ID: 7618032988 Enrollment ID: I20240118001798 |
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