Provider Demographics
NPI:1245789254
Name:STATTEL, MARY KATHRYN (MS, BA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:STATTEL
Suffix:
Gender:F
Credentials:MS, BA
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:STATTEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, BA
Mailing Address - Street 1:SUITE 110-1-3B CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-999-8105
Mailing Address - Fax:
Practice Address - Street 1:110 CHERRY ST
Practice Address - Street 2:SUITE 1-3B
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3938
Practice Address - Country:US
Practice Address - Phone:802-999-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097.0001240101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health