Healthcare Provider Details

I. General information

NPI: 1417015041
Provider Name (Legal Business Name): SYDNEY OBEDIN CRYSTAL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 ORCHARD ST
BRATTLEBORO VT
05301-4217
US

IV. Provider business mailing address

352 ORCHARD ST
BRATTLEBORO VT
05301-4217
US

V. Phone/Fax

Practice location:
  • Phone: 802-258-8242
  • Fax: 802-488-5714
Mailing address:
  • Phone: 802-258-8242
  • Fax: 802-488-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089-0000698
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: