Provider Demographics
NPI:1548215122
Name:PENOYAR, JOHN (MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PENOYAR
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 1:1041 POND RD
Mailing Address - Street 2:
Mailing Address - City:HINESBURG
Mailing Address - State:VT
Mailing Address - Zip Code:05461-9196
Mailing Address - Country:US
Mailing Address - Phone:802-860-8435
Mailing Address - Fax:
Practice Address - Street 1:1 MILL ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1530
Practice Address - Country:US
Practice Address - Phone:802-860-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005771Medicaid
VT1005771Medicaid