=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083740815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE BECKER WILSON LIC SW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 03/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 BENMONT AVE
-----------------------------------------------------
City | BENNINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05201-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-379-4548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 537
-----------------------------------------------------
City | N BENNINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05257-0537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-379-4548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0890000712
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------