Provider Demographics
NPI:1942303938
Name:ANDERSON, ELEANOR J (MA)
Entity Type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-0297
Mailing Address - Country:US
Mailing Address - Phone:802-649-2877
Mailing Address - Fax:
Practice Address - Street 1:289 MAIN STREET
Practice Address - Street 2:THE BURTON HOUSE
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055
Practice Address - Country:US
Practice Address - Phone:802-649-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470000548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT38813OtherBLUE CROSS BLUE SHIELD
VT1008448Medicaid