Provider Demographics
NPI:1629699848
Name:LERICHE-FORKEY, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:LERICHE-FORKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:VT
Mailing Address - Zip Code:05680
Mailing Address - Country:US
Mailing Address - Phone:802-696-9830
Mailing Address - Fax:
Practice Address - Street 1:1815 VT RTE 15
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:VT
Practice Address - Zip Code:05680-3008
Practice Address - Country:US
Practice Address - Phone:802-696-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0133681103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical