Provider Demographics
NPI:1740382043
Name:CORCORAN, DEAN MARK (MA)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:MARK
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 PEACHAM DANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BARNET
Mailing Address - State:VT
Mailing Address - Zip Code:05821-9400
Mailing Address - Country:US
Mailing Address - Phone:802-748-1516
Mailing Address - Fax:802-748-1516
Practice Address - Street 1:220 RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:ST. JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-1516
Practice Address - Fax:802-748-1516
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000422101Y00000X
VT000053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007051Medicaid