Provider Demographics
NPI:1912070350
Name:WATERSON, BARRY N (PSYAD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:N
Last Name:WATERSON
Suffix:
Gender:M
Credentials:PSYAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-0369
Mailing Address - Country:US
Mailing Address - Phone:802-272-0075
Mailing Address - Fax:
Practice Address - Street 1:331 UPPER PLN
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033
Practice Address - Country:US
Practice Address - Phone:802-272-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0122895103TC0700X, 103TC0700X
VT098-0000177103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006572Medicaid
NH30007402Medicaid
VT0626572OtherBCBS OF VERMONT
VT0006572Medicaid