Healthcare Provider Details

I. General information

NPI: 1265551147
Provider Name (Legal Business Name): KATHRYN C. STACKPOLE OSBORNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST
HYDE PARK VT
05655
US

IV. Provider business mailing address

PO BOX 24
LAKE ELMORE VT
05657-0024
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-6215
  • Fax: 802-888-9474
Mailing address:
  • Phone: 802-888-6215
  • Fax: 802-888-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089000725
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: