Basic Information
Provider Information | |||||||||
NPI: | 1922165489 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZOECKLEIN | ||||||||
FirstName: | EVELYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 240 SMITH RD | ||||||||
Address2: |   | ||||||||
City: | MORETOWN | ||||||||
State: | VT | ||||||||
PostalCode: | 056609217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024964865 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | RANDOLPH | ||||||||
State: | VT | ||||||||
PostalCode: | 050601330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027284466 | ||||||||
FaxNumber: | 8027284197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 08/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 068-0000607 | VT | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1009898 | 05 | VT |   | MEDICAID | 2163465 | 01 | VT | CIGNA | OTHER | 59560 | 01 | VT | BLUE CROSS | OTHER | 14Y001580VT01 | 01 | VT | ANTHEM | OTHER |