Provider Demographics
NPI:1881920965
Name:ELLISON, CASEY LYNN (ND)
Entity type:Individual
Prefix:MISS
First Name:CASEY
Middle Name:LYNN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 RIVER ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-3827
Mailing Address - Country:US
Mailing Address - Phone:802-505-0597
Mailing Address - Fax:707-440-4703
Practice Address - Street 1:174 RIVER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3827
Practice Address - Country:US
Practice Address - Phone:802-505-0597
Practice Address - Fax:707-440-4703
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X
VT099.0060043175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1017048Medicaid