Provider Demographics
NPI:1134401433
Name:MACCRELLISH, STUART MOORE (MSW)
Entity type:Individual
Prefix:MR
First Name:STUART
Middle Name:MOORE
Last Name:MACCRELLISH
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 1:653 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-2028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:653 QUARRY RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:VT
Practice Address - Zip Code:05472-2028
Practice Address - Country:US
Practice Address - Phone:802-989-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.00009711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical