Provider Demographics
NPI:1669438131
Name:FOWLER, BETSY A (LICSW)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:A
Last Name:FOWLER
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 1:714 BREEZY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-8882
Mailing Address - Country:US
Mailing Address - Phone:802-748-7500
Mailing Address - Fax:802-745-1188
Practice Address - Street 1:714 BREEZY HILL RD
Practice Address - Street 2:NVRH KINGDOM INTERNAL MEDICINE
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-8882
Practice Address - Country:US
Practice Address - Phone:802-748-7500
Practice Address - Fax:802-745-1188
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900010801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074593Medicaid
VT1011990Medicaid
NH3074593Medicaid