Provider Demographics
NPI:1497823199
Name:FERRIS, BLAINE (MS)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:FERRIS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5301
Mailing Address - Country:US
Mailing Address - Phone:802-658-0400
Mailing Address - Fax:802-660-3665
Practice Address - Street 1:300 FLYNN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5301
Practice Address - Country:US
Practice Address - Phone:802-658-0400
Practice Address - Fax:802-660-3665
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097-0000532103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical