Provider Demographics
NPI:1710063896
Name:LONGO, INGRID SCHOLZ (LICSW)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:SCHOLZ
Last Name:LONGO
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 1:36 BACK ST
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345-9523
Mailing Address - Country:US
Mailing Address - Phone:802-365-7111
Mailing Address - Fax:802-365-7111
Practice Address - Street 1:36 BACK ST
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:VT
Practice Address - Zip Code:05345-9523
Practice Address - Country:US
Practice Address - Phone:802-365-7111
Practice Address - Fax:802-365-7111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT4771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1736Medicaid
VT0VN1736Medicaid