Provider Demographics
NPI:1952819567
Name:WOLAK, RICHARD (MA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WOLAK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 STONEY MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-4343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:S BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6432
Practice Address - Country:US
Practice Address - Phone:802-658-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
12345OtherNA