Provider Demographics
NPI:1093467805
Name:STEVENS, SANDY (DCN, MT)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DCN, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2362
Mailing Address - Country:US
Mailing Address - Phone:802-379-4159
Mailing Address - Fax:
Practice Address - Street 1:160 BENMONT AVE FL WING2
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-379-4159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT225700000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty