Provider Demographics
NPI:1871661520
Name:REARDON, EILEEN MARIE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:MARIE
Last Name:REARDON
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 1:2 S MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4161
Mailing Address - Country:US
Mailing Address - Phone:802-773-3533
Mailing Address - Fax:802-773-3533
Practice Address - Street 1:2 S MAIN ST STE3
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4136
Practice Address - Country:US
Practice Address - Phone:802-773-3533
Practice Address - Fax:802-773-3533
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900005051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00069614OtherBLUE CROSS BLUE SHIELD OF
VT4151133OtherMVP HEALTH CARE
VT1012957Medicaid
VT003012701Medicare UPIN