Provider Demographics
NPI:1750413639
Name:LIBERTY, CAROLYN GILLIS I (LICSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GILLIS
Last Name:LIBERTY
Suffix:I
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MERCIER
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-5045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1459
Practice Address - Country:US
Practice Address - Phone:802-388-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00011391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015393Medicaid
VT1015393Medicaid