Provider Demographics
NPI:1154501880
Name:EGERTON, MARY JANE (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY JANE
Middle Name:
Last Name:EGERTON
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 1:506 TRIPP LANE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:802-748-9510
Mailing Address - Fax:
Practice Address - Street 1:506 TRIPP LANE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURG
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2911041C0700X
VT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006098Medicaid