Healthcare Provider Details

I. General information

NPI: 1891186227
Provider Name (Legal Business Name): SHELLEY ROLF LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 FAIRVIEW ST
BENNINGTON VT
05201-9239
US

IV. Provider business mailing address

171 CASTLE HILL AVE
GREAT BARRINGTON MA
01230-1051
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-1557
  • Fax:
Mailing address:
  • Phone: 413-429-6314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106349
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0000385
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: