Healthcare Provider Details

I. General information

NPI: 1538411640
Provider Name (Legal Business Name): JUDI DALY, LICSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 BLAIR PARK RD STE 210
WILLISTON VT
05495-7885
US

IV. Provider business mailing address

PO BOX 731
WATERBURY VT
05676-0731
US

V. Phone/Fax

Practice location:
  • Phone: 802-264-5333
  • Fax:
Mailing address:
  • Phone: 802-338-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0000186
License Number StateVT

VIII. Authorized Official

Name: JUDITH C DALY
Title or Position: SOLE MEMBER
Credential: LICSW
Phone: 802-338-7377