Basic Information
| Provider Information | |||||||||
| NPI: | 1427129857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | ED | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCMHC/LADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMSON | ||||||||
| OtherFirstName: | EDWARD | ||||||||
| OtherMiddleName: | HAMMER | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCMHC/LADC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 208 FLYNN AVE | ||||||||
| Address2: | 3-J | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886900 | ||||||||
| FaxNumber: | 8024886919 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886265 | ||||||||
| FaxNumber: | 8024886919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/20/2011 | ||||||||
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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 | 101YM0800X | 068-0000423 | VT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 0001000 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1007279 | 05 | VT | MEDICAID |