Provider Demographics
NPI:1669965554
Name:THORNDIKE, EDWARD (MA, AAP)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:THORNDIKE
Suffix:
Gender:M
Credentials:MA, AAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-5355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 OLD FARM RD
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4434
Practice Address - Country:US
Practice Address - Phone:802-578-0184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT097.0112163101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health