Healthcare Provider Details

I. General information

NPI: 1336685809
Provider Name (Legal Business Name): ELLIOTT BUELTER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ELLIOTT BUELTER LICSW

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 JOHNSON STREET EXT
HYDE PARK VT
05655-9354
US

IV. Provider business mailing address

156 JOHNSON STREET EXT
HYDE PARK VT
05655-9354
US

V. Phone/Fax

Practice location:
  • Phone: 802-851-0301
  • Fax:
Mailing address:
  • Phone: 401-714-4930
  • Fax: 401-712-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0134300
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: