Provider Demographics
NPI:1831371053
Name:HAUSER, HOLLY DALE (LICSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:DALE
Last Name:HAUSER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:DALE
Other - Last Name:HAUSER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:39 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05408-2466
Mailing Address - Country:US
Mailing Address - Phone:802-658-6786
Mailing Address - Fax:
Practice Address - Street 1:148 COLLEGE STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-861-2318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0000942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009457Medicaid