Healthcare Provider Details

I. General information

NPI: 1700607397
Provider Name (Legal Business Name): IDOLYN V. CARNAHAN, LICSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 MAIN ST
ST JOHNSBURY VT
05819-2646
US

IV. Provider business mailing address

PO BOX 111
ST JOHNSBURY VT
05819-0111
US

V. Phone/Fax

Practice location:
  • Phone: 603-718-0937
  • Fax:
Mailing address:
  • Phone: 603-718-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: IDOLYN VILLIOTTI CARNAHAN
Title or Position: MEMBER
Credential: LICSW
Phone: 603-718-0937