Provider Demographics
NPI:1396767802
Name:LARIVIERE, CYNTHIA LEIGH (PHD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEIGH
Last Name:LARIVIERE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SOUTH PROSPECT STREET,
Mailing Address - Street 2:UHC CAMPUS
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-847-4563
Mailing Address - Fax:
Practice Address - Street 1:1 S PROSPECT ST
Practice Address - Street 2:FAHC-PSYCHIATRY SERVICES
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3456
Practice Address - Country:US
Practice Address - Phone:802-847-4563
Practice Address - Fax:802-847-8747
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT517103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01257818Medicaid
VT0VN0103Medicaid
NY01257818Medicaid
VTLAVN0103Medicare ID - Type Unspecified