Provider Demographics
NPI:1568551703
Name:DUVAL, ELLEN MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:DUVAL
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 413
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05464-0413
Mailing Address - Country:US
Mailing Address - Phone:802-644-6758
Mailing Address - Fax:
Practice Address - Street 1:157 MAPLE ST.
Practice Address - Street 2:#3
Practice Address - City:JEFFERSONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05464
Practice Address - Country:US
Practice Address - Phone:802-644-6758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00007781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012011Medicaid