Provider Demographics
NPI:1255475554
Name:CLODFELTER, LORRAINE K (MS)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:K
Last Name:CLODFELTER
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 1:921 OLD WEST CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ADAMANT
Mailing Address - State:VT
Mailing Address - Zip Code:05640-7017
Mailing Address - Country:US
Mailing Address - Phone:802-229-0967
Mailing Address - Fax:
Practice Address - Street 1:18 LANGDON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3080
Practice Address - Country:US
Practice Address - Phone:802-223-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT258103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1004331Medicaid