Provider Demographics
NPI:1639259914
Name:CARPENTER, MARC D (MA PSYCHOLOGIST-MAST)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:D
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:MA PSYCHOLOGIST-MAST
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 995
Mailing Address - Street 2:
Mailing Address - City:WEST RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05777-0995
Mailing Address - Country:US
Mailing Address - Phone:802-438-8282
Mailing Address - Fax:802-748-4405
Practice Address - Street 1:1085 US ROUTE 4 E STE 2A
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-8007
Practice Address - Country:US
Practice Address - Phone:802-438-8282
Practice Address - Fax:802-748-4405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470000606103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007272Medicaid
VT00039430OtherBCBS