Provider Demographics
NPI:1568641496
Name:MARY ANN DATTILO BOYD PLLC
Entity Type:Organization
Organization Name:MARY ANN DATTILO BOYD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:DATTILO
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-349-6182
Mailing Address - Street 1:135 S PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-4456
Mailing Address - Country:US
Mailing Address - Phone:802-349-6182
Mailing Address - Fax:
Practice Address - Street 1:135 S PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-4456
Practice Address - Country:US
Practice Address - Phone:802-349-6182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-27
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900010581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011288Medicaid
VTVN3894Medicare PIN
VT1011288Medicaid
VTUX9571Medicare PIN