Provider Demographics
NPI:1578604310
Name:UNIVERSITY OF VERMONT AND STATE AGRICULTURAL COLLEGE
Entity Type:Organization
Organization Name:UNIVERSITY OF VERMONT AND STATE AGRICULTURAL COLLEGE
Other - Org Name:ELEANOR M. LUSE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:802-656-0202
Mailing Address - Street 1:489 MAIN ST
Mailing Address - Street 2:POMEROY HALL
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05405-1709
Mailing Address - Country:US
Mailing Address - Phone:802-656-3861
Mailing Address - Fax:802-656-2528
Practice Address - Street 1:489 MAIN ST
Practice Address - Street 2:POMEROY HALL
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-1709
Practice Address - Country:US
Practice Address - Phone:802-656-3861
Practice Address - Fax:802-656-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00002672OtherBCBS
64008OtherMVP
VT1005859Medicaid