Provider Demographics
NPI:1093376097
Name:DEARTH, KATELYN MICHELLE (LICSW, AAP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MICHELLE
Last Name:DEARTH
Suffix:
Gender:F
Credentials:LICSW, AAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 SHELBURNE RD STE D2
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7753
Mailing Address - Country:US
Mailing Address - Phone:802-859-1577
Mailing Address - Fax:802-859-1571
Practice Address - Street 1:1233 SHELBURNE RD STE D2
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7753
Practice Address - Country:US
Practice Address - Phone:802-859-1577
Practice Address - Fax:802-859-1571
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01342031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical