Provider Demographics
NPI:1629107156
Name:COULTER, MARTHA JEAN (MED)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:JEAN
Last Name:COULTER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 S. MAIN ST.
Mailing Address - Street 2:RCSU
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-773-1411
Mailing Address - Fax:802-775-7319
Practice Address - Street 1:128 MERCHANTS ROW
Practice Address - Street 2:6TH FLOOR
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5909
Practice Address - Country:US
Practice Address - Phone:802-773-1411
Practice Address - Fax:802-775-7319
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000194-1101YM0800X
VT0470000386103T00000X
VT103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT956673OtherMVP
NYVF6352OtherEMPIRE BC/BS
VT1002138Medicaid
VT062-2690OtherBLUE CROSS AND BLUE SHLD
VT120304000OtherMAGELLAN HEALTH SERVICES
VT2028356OtherCIGNA