Provider Demographics
NPI:1720367907
Name:SHRIVER-BLAKE, MOLLY (LCSW)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SHRIVER-BLAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SUBURBAN SQ
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6458
Mailing Address - Country:US
Mailing Address - Phone:802-595-9278
Mailing Address - Fax:
Practice Address - Street 1:102 SUBURBAN SQ
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6458
Practice Address - Country:US
Practice Address - Phone:802-595-9278
Practice Address - Fax:802-595-9278
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0063711041C0700X
VT089.01002671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty