Provider Demographics
NPI:1396016150
Name:CHIVINGTON, KATIE RAE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:RAE
Last Name:CHIVINGTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4705 VT ROUTE 100
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:VT
Mailing Address - Zip Code:05655-9613
Mailing Address - Country:US
Mailing Address - Phone:802-585-5510
Mailing Address - Fax:
Practice Address - Street 1:632 MORRISTOWN CORNERS RD
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8985
Practice Address - Country:US
Practice Address - Phone:802-585-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0073477171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist