Provider Demographics
NPI:1033280177
Name:PEDERSEN, KATHRYN A (MA (2) LCMHC)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:A
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MA (2) LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4520
Practice Address - Street 1:390 RIVER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2226
Practice Address - Country:US
Practice Address - Phone:802-886-4500
Practice Address - Fax:802-886-4520
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9491101YM0800X
VT068.0000365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006702Medicaid