Provider Demographics
NPI:1659435147
Name:SADLAK, MARY JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY JEAN
Middle Name:
Last Name:SADLAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BENMONT AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1873
Mailing Address - Country:US
Mailing Address - Phone:802-442-3520
Mailing Address - Fax:802-447-3392
Practice Address - Street 1:160 BENMONT AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-442-3520
Practice Address - Fax:802-447-3392
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000505103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0349Medicaid
VTVN0349Medicare PIN