Provider Demographics
NPI:1679652002
Name:ZILBOORG, MATTHEW STONE (MACP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STONE
Last Name:ZILBOORG
Suffix:
Gender:M
Credentials:MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PATCHEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-5704
Mailing Address - Country:US
Mailing Address - Phone:802-658-4208
Mailing Address - Fax:802-658-2234
Practice Address - Street 1:34 PATCHEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5704
Practice Address - Country:US
Practice Address - Phone:802-658-4208
Practice Address - Fax:802-658-2234
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000317103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN3440Medicare ID - Type Unspecified