Healthcare Provider Details

I. General information

NPI: 1568071322
Provider Name (Legal Business Name): MR. MAXWELL ALEXANDER DUQUETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 OLD FARM RD
STOWE VT
05672-4434
US

IV. Provider business mailing address

539 SPRUCE HAVEN RD
WATERBURY CENTER VT
05677-8065
US

V. Phone/Fax

Practice location:
  • Phone: 802-373-2909
  • Fax:
Mailing address:
  • Phone: 802-585-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number097.0134809
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: