Provider Demographics
NPI:1083740815
Name:WILSON, GRACE BECKER (LIC SW)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:BECKER
Last Name:WILSON
Suffix:
Gender:F
Credentials:LIC SW
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 537
Mailing Address - Street 2:
Mailing Address - City:N BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05257-0537
Mailing Address - Country:US
Mailing Address - Phone:802-379-4548
Mailing Address - Fax:
Practice Address - Street 1:160 BENMONT AVE
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-379-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900007121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1867Medicaid
VTOVN1867Medicaid