Provider Demographics
NPI:1164589735
Name:CHALOM, KAREN EDANA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:EDANA
Last Name:CHALOM
Suffix:
Gender:F
Credentials:LICSW
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 109
Mailing Address - Street 2:4056 POMFRET ROAD
Mailing Address - City:SOUTH POMFRET
Mailing Address - State:VT
Mailing Address - Zip Code:05067-0109
Mailing Address - Country:US
Mailing Address - Phone:802-457-6191
Mailing Address - Fax:802-457-6191
Practice Address - Street 1:4056 POMFRET ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH POMFRET
Practice Address - State:VT
Practice Address - Zip Code:05067-0109
Practice Address - Country:US
Practice Address - Phone:802-457-6191
Practice Address - Fax:802-457-6191
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900009961041C0700X
MN127941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011535Medicaid
VT1011535Medicaid