Provider Demographics
NPI:1831291418
Name:BOEDY, DAVID LEE (MSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LEE
Last Name:BOEDY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAIN ST
Mailing Address - Street 2:STE #216
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5216
Mailing Address - Country:US
Mailing Address - Phone:802-651-7501
Mailing Address - Fax:802-860-1234
Practice Address - Street 1:3 MAIN ST
Practice Address - Street 2:STE #216
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5216
Practice Address - Country:US
Practice Address - Phone:802-651-7501
Practice Address - Fax:802-860-1234
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0495Medicaid
VTVN0495Medicare ID - Type Unspecified