Healthcare Provider Details

I. General information

NPI: 1396382628
Provider Name (Legal Business Name): DIANE PAULETTE COLLIAS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 PARK AVE
WILLISTON VT
05495-9701
US

IV. Provider business mailing address

28 PARK AVE
WILLISTON VT
05495-9701
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-1008
  • Fax: 802-872-2679
Mailing address:
  • Phone: 802-878-1008
  • Fax: 802-872-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0089765
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: