Provider Demographics
NPI:1255421004
Name:MATIACH, ELIZAVETA (MS, LPM)
Entity type:Individual
Prefix:
First Name:ELIZAVETA
Middle Name:
Last Name:MATIACH
Suffix:
Gender:F
Credentials:MS, LPM
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 749
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0749
Mailing Address - Country:US
Mailing Address - Phone:802-851-8619
Mailing Address - Fax:802-851-8716
Practice Address - Street 1:607 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8652
Practice Address - Country:US
Practice Address - Phone:802-888-8320
Practice Address - Fax:802-888-8136
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0000698103TC0700X
VT151.0127410101YA0400X
VT047-0000698103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007708Medicaid
VT2081698OtherCIGNA
VT00058059OtherBCBS
VT615535OtherMVP