=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669023701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTA MORDOFF LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2019
-----------------------------------------------------
Last Update Date | 12/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 PEARL ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-8564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-206-0175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 MAZZA CT
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-3827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 089-0130482
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------