Provider Demographics
NPI:1831569862
Name:ST JOHNSBURY PSYCHOLOGY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:ST JOHNSBURY PSYCHOLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:802-751-9347
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0132
Mailing Address - Country:US
Mailing Address - Phone:802-751-9347
Mailing Address - Fax:
Practice Address - Street 1:1097 MAIN ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2646
Practice Address - Country:US
Practice Address - Phone:802-751-9347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0052907103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018468OtherMEDICARE PTAN
VT1017870Medicaid