Provider Demographics
NPI:1003073644
Name:RENAUDETTE, MARILYN JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JEAN
Last Name:RENAUDETTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:JEAN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:55 IAN PL
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4408
Mailing Address - Country:US
Mailing Address - Phone:802-764-1282
Mailing Address - Fax:802-764-1282
Practice Address - Street 1:4185 ST GEORGE RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7695
Practice Address - Country:US
Practice Address - Phone:802-651-7730
Practice Address - Fax:802-651-7730
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000736103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015179Medicaid