Provider Demographics
NPI:1760631774
Name:MICHALCZUK, DIANA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:MICHALCZUK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-9810
Mailing Address - Country:US
Mailing Address - Phone:802-447-1409
Mailing Address - Fax:802-442-5199
Practice Address - Street 1:357 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-9810
Practice Address - Country:US
Practice Address - Phone:802-447-1409
Practice Address - Fax:802-442-5199
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0086156103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT003006801OtherMEDICARE PTAN
VTP01173650OtherRAILROAD MEDICARE