Provider Demographics
NPI:1043339773
Name:TISDALE, DEMARIS (MSW)
Entity Type:Individual
Prefix:MS
First Name:DEMARIS
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SNIPE IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-9691
Mailing Address - Country:US
Mailing Address - Phone:802-434-3941
Mailing Address - Fax:
Practice Address - Street 1:69 BARRE ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3504
Practice Address - Country:US
Practice Address - Phone:802-229-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00002311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009816Medicaid
VT0009816Medicaid