Provider Demographics
NPI:1972718146
Name:SPRAGUE, ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:SPRAGUE
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 1:1 KENNEDY DR STE L8
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7165
Mailing Address - Country:US
Mailing Address - Phone:802-860-1002
Mailing Address - Fax:802-658-8494
Practice Address - Street 1:1 KENNEDY DR STE L8
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7165
Practice Address - Country:US
Practice Address - Phone:802-860-1002
Practice Address - Fax:802-658-8494
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT59431OtherBLUE CROSS BLUE SHIELD ID
VT1009110Medicaid