Provider Demographics
NPI:1952312373
Name:WATULAK, GARY WAYNE (MS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:WAYNE
Last Name:WATULAK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3404
Mailing Address - Country:US
Mailing Address - Phone:802-775-6031
Mailing Address - Fax:802-775-6031
Practice Address - Street 1:26 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3404
Practice Address - Country:US
Practice Address - Phone:802-775-6031
Practice Address - Fax:802-775-6031
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470000240103TB0200X, 103TC1900X, 103TF0000X, 103TP2701X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
51742OtherCIGNA
VT0006590Medicaid
VT331856OtherMHN
11326073OtherCAQH
VT691411OtherMVP
VT6590OtherBCBS
11326073OtherCAQH