Provider Demographics
NPI:1427110188
Name:BLEAU, TINA L (MA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:BLEAU
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3150
Mailing Address - Country:US
Mailing Address - Phone:802-288-9986
Mailing Address - Fax:
Practice Address - Street 1:30 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:S BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6432
Practice Address - Country:US
Practice Address - Phone:802-658-3924
Practice Address - Fax:802-658-0216
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000688103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2252996OtherCIGNA PROVIDER NUMBER
VT00048412OtherBC BS PROVIDER NUMBER
VT389998OtherMVP PROVIDER NUMBER
VT1011221Medicaid