NPIMap

Organization Active NPI

Maple Leaf Clinic PC

  • Clinical Psychologist
  • Wallingford, VT
National Provider Identifier
1851715635
Registry record updated Feb 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
620 Issued in VT
Legal business name
MAPLE LEAF CLINIC PC
Practice address
167 N Main St
Wallingford, VT 05773-9800
Phone
(802) 446-3577
Fax
(802) 446-3801
NPI assigned
Feb 13, 2014
Last updated
Feb 5, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 5, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dean J MooneyNPI 1568686822
Title
Owner
Phone
(802) 446-3577

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 620 VT Primary

Addresses

Primary practice location

167 N Main St
Wallingford, VT 05773-9800

Mailing address

167 N Main St
Wallingford, VT 05773-9800
Phone (802) 446-3577

Other identifiers 1

IdentifierTypeStateIssuer
1022361MedicaidVT

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210216001561 VT Part B Supplier - Clinic/Group Practice 8426463951 Receives reassigned benefits from 4 practitioners
Practice locations: Wallingford, VT

National Provider Directory

National Provider Directory

Locations

167 N Main St
Wallingford, VT 05773
Phone (802) 353-3537

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1392249600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612483200000",
    "number": "1851715635",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "167 N MAIN ST",
            "city": "WALLINGFORD",
            "state": "VT",
            "postal_code": "057739800",
            "telephone_number": "802-446-3577",
            "fax_number": "802-446-3801"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "167 N MAIN ST",
            "city": "WALLINGFORD",
            "state": "VT",
            "postal_code": "057739800",
            "telephone_number": "802-446-3577",
            "fax_number": "802-446-3801"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAPLE LEAF CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-13",
        "last_updated": "2021-02-05",
        "certification_date": "2021-02-05",
        "status": "A",
        "authorized_official_last_name": "MOONEY",
        "authorized_official_first_name": "DEAN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "802-446-3577"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "VT",
            "license": "620",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1022361",
            "state": "VT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wallingford, VT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.