Facts
- Status
- A
- Credential
- LICSW, LADC
- Type
- Individual
- Enumeration date
- 2016-02-23
- Last updated
- 2016-02-23
Licenses
- License VT
- 000703
- License VT
- 89.0099956
Location
- Practice location
- 900 MAIN ST
- City
- FAIRFAX VT
- Postal code
- 054549526
- Phone
- 802-849-2639
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.