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General NPI Number Information
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NPI Number | 1043339773
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Entity Type | Individual
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Provider Name | DEMARIS TISDALE M.S.W.
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Gender | Female
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 69 BARRE ST
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City | MONTPELIER
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State | VT
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Zip | 05602-3504
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Country | US
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Telephone | 802-229-2770
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Fax |
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Provider Business Mailing Address
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Address Line | 1125 SNIPE IRELAND RD
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City | RICHMOND
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State | VT
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Zip | 05477-9691
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Country | US
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Telephone | 802-434-3941
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 089-0000231
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License Number State | VT
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