Provider Demographics
NPI:1114034295
Name:IAZZO, DEBORAH E (PHD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:E
Last Name:IAZZO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:E
Other - Last Name:IAZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:130 FISHER RD
Mailing Address - Street 2:STE 1-6
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9516
Mailing Address - Country:US
Mailing Address - Phone:802-223-9150
Mailing Address - Fax:802-223-9151
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:STE 1-6
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-223-9150
Practice Address - Fax:802-223-9151
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000806103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTIAVN2834Medicare ID - Type UnspecifiedM/CARE PROVIDER NUMBER