Provider Demographics
NPI:1164479978
Name:GADOS, MARY E (MSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GADOS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SAN REMO DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6343
Mailing Address - Country:US
Mailing Address - Phone:802-865-0010
Mailing Address - Fax:802-865-0050
Practice Address - Street 1:23 SAN REMO DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6343
Practice Address - Country:US
Practice Address - Phone:802-865-0010
Practice Address - Fax:802-865-0050
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003314174400000X
NY020816-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012150Medicaid
VT00058693OtherBC/BS
VTOOO3314OtherVT MANAGED CARE
VT385696OtherMVP
VTOOO3314OtherVT MANAGED CARE