Provider Demographics
NPI:1164687174
Name:HASELDINE, SANDRA JANE (LCMHC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JANE
Last Name:HASELDINE
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 HARDSCRABBLE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3153
Mailing Address - Country:US
Mailing Address - Phone:802-735-3061
Mailing Address - Fax:
Practice Address - Street 1:133 BLAKELY RD
Practice Address - Street 2:SUITE 14
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-4007
Practice Address - Country:US
Practice Address - Phone:802-735-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-20
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010857Medicaid
VT12065721OtherQAQH