Provider Demographics
NPI:1073261517
Name:RAILLA, NATHAN (LCMHC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:RAILLA
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 PATNEAUDE LN
Mailing Address - Street 2:
Mailing Address - City:BARNET
Mailing Address - State:VT
Mailing Address - Zip Code:05821-9650
Mailing Address - Country:US
Mailing Address - Phone:303-667-9060
Mailing Address - Fax:
Practice Address - Street 1:147 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:BARNET
Practice Address - State:VT
Practice Address - Zip Code:05821
Practice Address - Country:US
Practice Address - Phone:303-667-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0134331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health