Provider Demographics
NPI:1225505381
Name:BERRY-BERARD, LICIA LANE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:LICIA
Middle Name:LANE
Last Name:BERRY-BERARD
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 44
Mailing Address - Street 2:
Mailing Address - City:NORTH THETFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05054
Mailing Address - Country:US
Mailing Address - Phone:802-356-1580
Mailing Address - Fax:603-650-6392
Practice Address - Street 1:312 CLAY RD
Practice Address - Street 2:
Practice Address - City:NORTH THETFORD
Practice Address - State:VT
Practice Address - Zip Code:05054-0505
Practice Address - Country:US
Practice Address - Phone:802-698-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0891341871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical