Provider Demographics
NPI:1386709905
Name:KOVACHICH II, VIRGIL JOHN (MA,LADC,LCMHC)
Entity type:Individual
Prefix:
First Name:VIRGIL
Middle Name:JOHN
Last Name:KOVACHICH II
Suffix:
Gender:M
Credentials:MA,LADC,LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:BARTON
Mailing Address - State:VT
Mailing Address - Zip Code:05822-0156
Mailing Address - Country:US
Mailing Address - Phone:802-525-4529
Mailing Address - Fax:
Practice Address - Street 1:103 SCHOOL STREET
Practice Address - Street 2:SUITE D
Practice Address - City:BARTON
Practice Address - State:VT
Practice Address - Zip Code:05822-0156
Practice Address - Country:US
Practice Address - Phone:802-525-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000135101YA0400X
VT068-0000570101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008371Medicaid
VT391759OtherMVP
VT58531OtherBCBS