Provider Demographics
NPI:1174666515
Name:DESRAULT, NANCY J (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:DESRAULT
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 PINE STREET
Mailing Address - Street 2:THE MALTEX BLDG
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-865-9873
Mailing Address - Fax:802-865-9877
Practice Address - Street 1:431 PINE STREET
Practice Address - Street 2:THE MALTEX BLDG
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-865-9873
Practice Address - Fax:802-865-9877
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900003471041C0700X
PASW00632861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical