Provider Demographics
NPI:1801440540
Name:PARKS, ANGELIQUE (MA, LCMHC)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2046
Mailing Address - Country:US
Mailing Address - Phone:802-881-9519
Mailing Address - Fax:
Practice Address - Street 1:168 NORTH ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1874
Practice Address - Country:US
Practice Address - Phone:802-342-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT068.0134668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program