Provider Demographics
NPI:1265619183
Name:GLEASON, THERESA CHANCE (LICSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:CHANCE
Last Name:GLEASON
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 1:2076 EAST ST
Mailing Address - Street 2:
Mailing Address - City:BRIDPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05734-9680
Mailing Address - Country:US
Mailing Address - Phone:802-758-2476
Mailing Address - Fax:
Practice Address - Street 1:2076 EAST ST
Practice Address - Street 2:
Practice Address - City:BRIDPORT
Practice Address - State:VT
Practice Address - Zip Code:05734-9680
Practice Address - Country:US
Practice Address - Phone:802-758-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00001961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical