Provider Demographics
NPI:1417995051
Name:DESMARAIS, TINA L (MA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:L
Last Name:DESMARAIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05667-9050
Mailing Address - Country:US
Mailing Address - Phone:802-223-1177
Mailing Address - Fax:802-223-1177
Practice Address - Street 1:879 GRAY RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:VT
Practice Address - Zip Code:05667-9050
Practice Address - Country:US
Practice Address - Phone:802-223-1177
Practice Address - Fax:802-223-1177
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0000446101YM0800X
VT068-0000446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006769Medicaid