Basic Information
Provider Information | |||||||||
NPI: | 1437358785 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYERSON | ||||||||
FirstName: | DEANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POLLET | ||||||||
OtherFirstName: | DEANNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 208 FLYNN AVE STE 3J | ||||||||
Address2: |   | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 054015420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024886920 | ||||||||
FaxNumber: | 8024886919 | ||||||||
Practice Location | |||||||||
Address1: | 1138 PINE ST | ||||||||
Address2: |   | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 054015353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024886000 | ||||||||
FaxNumber: | 8024886919 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2007 | ||||||||
LastUpdateDate: | 12/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3225 | CO | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 048-0134129 | VT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.