Provider Demographics
NPI:1760029474
Name:WALDMAN, EVAN (LCMHC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SMUGGLERS VIEW RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05464-9507
Mailing Address - Country:US
Mailing Address - Phone:802-730-2534
Mailing Address - Fax:
Practice Address - Street 1:275 VT 15 W
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:VT
Practice Address - Zip Code:05656-9657
Practice Address - Country:US
Practice Address - Phone:802-585-0703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0065445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional