Provider Demographics
NPI:1194851691
Name:WERNER-GAVRIN, MARC RICHARD
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:RICHARD
Last Name:WERNER-GAVRIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-1011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443-1011
Practice Address - Country:US
Practice Address - Phone:802-453-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist