Healthcare Provider Details

I. General information

NPI: 1962838904
Provider Name (Legal Business Name): GRACE JANOVE MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRAY JANOVE

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 FAIRVIEW STREET
BRATTLEBORO VT
05301-6629
US

IV. Provider business mailing address

390 RIVER STREET
SPRINGFIELD VT
05156-2226
US

V. Phone/Fax

Practice location:
  • Phone: 802-254-6028
  • Fax: 802-254-7501
Mailing address:
  • Phone: 802-886-4500
  • Fax: 802-886-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0970134666
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number221702
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: