Provider Demographics
NPI:1053312264
Name:BLEECKER, KARIN E (MS)
Entity Type:Individual
Prefix:MS
First Name:KARIN
Middle Name:E
Last Name:BLEECKER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 SIGNAL HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-4101
Mailing Address - Country:US
Mailing Address - Phone:717-273-1710
Mailing Address - Fax:717-273-1416
Practice Address - Street 1:6079 MAIN ST
Practice Address - Street 2:
Practice Address - City:E PETERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17520-1267
Practice Address - Country:US
Practice Address - Phone:717-560-1908
Practice Address - Fax:717-560-4941
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007210L103T00000X
VT047.0097608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL748408OtherBC BS