Basic Information
| Provider Information | |||||||||
| NPI: | 1255421004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATIACH | ||||||||
| FirstName: | ELIZAVETA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 749 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056610749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028518603 | ||||||||
| FaxNumber: | 8028518313 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 NORTHGATE PLAZA | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056615900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028888320 | ||||||||
| FaxNumber: | 8028888136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 047-0000698 | VT | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1007708 | 05 | VT | MEDICAID | 615535 | 01 | VT | MVP | OTHER | 2081698 | 01 | VT | CIGNA | OTHER | 00058059 | 01 | VT | BCBS | OTHER |