Provider Demographics
NPI:1750594180
Name:DEHAVEN, MARY CLAIRE (MSW)
Entity type:Individual
Prefix:MS
First Name:MARY CLAIRE
Middle Name:
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 JERUSALEM RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-5326
Mailing Address - Country:US
Mailing Address - Phone:802-349-7095
Mailing Address - Fax:
Practice Address - Street 1:63 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1602
Practice Address - Country:US
Practice Address - Phone:802-349-7095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900004391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007733Medicaid
VT38212OtherBLUE CROSS BLUE SHIELD
VT38212OtherMAGELLAN
VT4128154OtherUNITED BEHAVIORAL HEALTH
VT2031021OtherCIGNA
VT411V121OtherMVP