Provider Demographics
NPI:1588631543
Name:STANDARD, SAMUEL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:STANDARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3351
Mailing Address - Country:US
Mailing Address - Phone:802-864-0990
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FLETCHER ALLEN HEALTH CARE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist