Provider Demographics
NPI:1851715635
Name:MAPLE LEAF CLINIC PC
Entity Type:Organization
Organization Name:MAPLE LEAF CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-446-3577
Mailing Address - Street 1:167 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05773-9800
Mailing Address - Country:US
Mailing Address - Phone:802-446-3577
Mailing Address - Fax:802-446-3801
Practice Address - Street 1:167 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:VT
Practice Address - Zip Code:05773-9800
Practice Address - Country:US
Practice Address - Phone:802-446-3577
Practice Address - Fax:802-446-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022361Medicaid