Provider Demographics
NPI:1881769107
Name:KNISELY, STEPHEN M (LICSW)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:M
Last Name:KNISELY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:160 ALLEN STREET
Mailing Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-747-1857
Mailing Address - Fax:802-747-0129
Practice Address - Street 1:160 ALLEN STREET
Practice Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-747-1857
Practice Address - Fax:802-747-0129
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT08900011441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012896Medicaid
VT1012896Medicaid