=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215640545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYRA HANDY LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3117 GUINEA RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05445-8702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-999-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3117 GUINEA RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05445-8702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-999-7983
-----------------------------------------------------
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 | 089.0000911
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------