Basic Information
| Provider Information | |||||||||
| NPI: | 1053312264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEECKER | ||||||||
| FirstName: | KARIN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 SIGNAL HILL DR | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053014101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172731710 | ||||||||
| FaxNumber: | 7172731416 | ||||||||
| Practice Location | |||||||||
| Address1: | 6079 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | E PETERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175201267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175601908 | ||||||||
| FaxNumber: | 7175604941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS007210L | PA | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 047.0097608 | VT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | BL748408 | 01 | BC BS | OTHER |