=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528507076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER BERT HENRY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 PAINE MOUNTAIN DR
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05663-5791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-485-4161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 COLCHESTER AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-847-0000
-----------------------------------------------------
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 | 3830
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 089.0134266
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------