Healthcare Provider Details

I. General information

NPI: 1073047684
Provider Name (Legal Business Name): NANCY GORE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N MAIN ST STE 7
BARRE VT
05641-4145
US

IV. Provider business mailing address

555 AUBURN ST
MANCHESTER NH
03103-4803
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-1955
  • Fax:
Mailing address:
  • Phone: 603-621-3516
  • Fax: 603-622-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.123308
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: