Healthcare Provider Details

I. General information

NPI: 1609434349
Provider Name (Legal Business Name): STASIA DZIUBEK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 PINE ST
BURLINGTON VT
05401-5353
US

IV. Provider business mailing address

208 FLYNN AVE STE 3J
BURLINGTON VT
05401-5420
US

V. Phone/Fax

Practice location:
  • Phone: 802-488-6000
  • Fax: 802-488-6919
Mailing address:
  • Phone: 802-488-6934
  • Fax: 802-488-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089-0120735
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: