MEDICARE: THERESA CHANCE GLEASON LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	089-0000196	VT

General Provider Information

NPI Number	:	1265619183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA CHANCE GLEASON LICSW

Provider Business Mailing Address
First Line	:	2076 EAST ST
Second Line	:
City	:	BRIDPORT
State	:	VT
Zip	:	05734-9680
Country	:	US
Telephone Number	:	802-758-2476
Fax Number	:

Provider Business Practice Location Address
First Line	:	2076 EAST ST
Second Line	:
City	:	BRIDPORT
State	:	VT
Zip	:	05734-9680
Country	:	US
Telephone Number	:	802-758-2476
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2008
Last Update Date	:	01/22/2008

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