Basic Information
| Provider Information | |||||||||
| NPI: | 1285004200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTERSON | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORRESTALL | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 208 FLYNN AVE | ||||||||
| Address2: | SUITE 3J | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015429 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1138 PINE ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-9520 | VT | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.