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General NPI Number Information
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NPI Number | 1134842909
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Entity Type | Organization
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Legal Business Name | DRIFT MAVYN LICSW LLC
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Dates
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Enumeration Date | 09/26/2022
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | 74 GRAFTON RD.
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City | TOWNSHEND
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State | VT
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Zip | 05353
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Country | US
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Telephone | 802-321-5066
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Fax | 802-210-3972
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Provider Business Mailing Address
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Address Line | PO BOX 157
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City | TOWNSHEND
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State | VT
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Zip | 05353-0157
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Country | US
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Telephone | 802-321-5066
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Fax | 802-210-3972
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Authorized Official
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Title or Position | OWNER
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Name | DRIFT E MAVYN
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Credential | MSW, LICSW
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Telephone | 802-321-5066
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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 |
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License Number State |
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