Provider Demographics
NPI:1285679985
Name:LUSSARDI, DARIO J (MA)
Entity Type:Individual
Prefix:
First Name:DARIO
Middle Name:J
Last Name:LUSSARDI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COLDBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05363-9624
Mailing Address - Country:US
Mailing Address - Phone:802-464-5550
Mailing Address - Fax:802-464-3657
Practice Address - Street 1:25 COLDBROOK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:VT
Practice Address - Zip Code:05363-9624
Practice Address - Country:US
Practice Address - Phone:802-464-5550
Practice Address - Fax:802-464-3657
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00002609OtherBLUE CROSS & BLUE SHIELD
VT0002609Medicaid