Provider Demographics
NPI:1699124388
Name:HANIFIN, ALICIA R
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:HANIFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 MAIN ST. SUITE 19
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-2932
Mailing Address - Country:US
Mailing Address - Phone:413-847-1571
Mailing Address - Fax:
Practice Address - Street 1:73 MAIN ST RM 19
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2944
Practice Address - Country:US
Practice Address - Phone:413-847-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT120056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical