Basic Information
Provider Information | |||||||||
NPI: | 1629066352 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIESHEUVEL | ||||||||
FirstName: | DESIREE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 390 RIVER ST. | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | VT | ||||||||
PostalCode: | 051562226 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028864500 | ||||||||
FaxNumber: | 8028864520 | ||||||||
Practice Location | |||||||||
Address1: | 289 COUNTY RD | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | VT | ||||||||
PostalCode: | 050899000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8026747300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 03/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 042-0010777 | VT | N |   | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 2084P0804X | 042-0010777 | VT | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1010701 | 05 | VT |   | MEDICAID | T-0552 | 01 | NH | TEMPORARY MEDICAL LICENSE | OTHER |