Provider Demographics
NPI:1720039860
Name:STOLL, MIRIAM FREDA (PHD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:FREDA
Last Name:STOLL
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 1:2 COLCHETER AVENUE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05405-0134
Mailing Address - Country:US
Mailing Address - Phone:802-656-2661
Mailing Address - Fax:802-656-3482
Practice Address - Street 1:2 COLCHETER AVENUE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-0134
Practice Address - Country:US
Practice Address - Phone:802-656-2661
Practice Address - Fax:802-656-3482
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000807103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009132Medicaid
VT59091OtherBCBS
VT59091OtherBCBS