Provider Demographics
NPI:1134273154
Name:BOMENGEN, JULIE LYNNE (MS)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:LYNNE
Last Name:BOMENGEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3491 ELMORE MTN RD
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661
Mailing Address - Country:US
Mailing Address - Phone:802-888-9345
Mailing Address - Fax:
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:GRANT BUILDING
Practice Address - City:HYDE PARK
Practice Address - State:VT
Practice Address - Zip Code:05655
Practice Address - Country:US
Practice Address - Phone:802-888-6215
Practice Address - Fax:802-888-9474
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008302Medicaid