Healthcare Provider Details

I. General information

NPI: 1710063896
Provider Name (Legal Business Name): INGRID SCHOLZ LONGO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BACK ST
NEWFANE VT
05345-9523
US

IV. Provider business mailing address

36 BACK ST
NEWFANE VT
05345-9523
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-7111
  • Fax: 802-365-7111
Mailing address:
  • Phone: 802-365-7111
  • Fax: 802-365-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number477
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: