Provider Demographics
NPI:1376879387
Name:POLSENO, NANCY RAE
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:RAE
Last Name:POLSENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PARK PL
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-2821
Mailing Address - Country:US
Mailing Address - Phone:802-254-1234
Mailing Address - Fax:
Practice Address - Street 1:14 PARK PL
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2821
Practice Address - Country:US
Practice Address - Phone:802-254-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health