Provider Demographics
NPI:1275079121
Name:DUTKIEWICZ, MARC (LADC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:DUTKIEWICZ
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 FAIRFAX ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-5122
Mailing Address - Country:US
Mailing Address - Phone:802-309-2140
Mailing Address - Fax:
Practice Address - Street 1:132 S MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1891
Practice Address - Country:US
Practice Address - Phone:802-309-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)