Basic Information
| Provider Information | |||||||||
| NPI: | 1326100538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOLTENBERG | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 FLYNN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026580404 | ||||||||
| FaxNumber: | 8026603665 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 FLYNN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026580404 | ||||||||
| FaxNumber: | 8026603665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 048-0000223 | VT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0006575 | 05 | VT | MEDICAID |