Healthcare Provider Details

I. General information

NPI: 1528350295
Provider Name (Legal Business Name): SHELLY HOULE RODRIGUEZ LCMHC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLY MARIE HOULE LADC

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 UPPER PLEASANT VALLEY RD
JEFFERSONVILLE VT
05444
US

IV. Provider business mailing address

272 NORTH MAINE STREET ROOM # 223
CAMBRIDGE VT
05444
US

V. Phone/Fax

Practice location:
  • Phone: 802-324-4803
  • Fax:
Mailing address:
  • Phone: 802-644-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000482
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0680057754
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: