=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730897778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SARA J DEMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2022
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1097 MAIN ST
-----------------------------------------------------
City | ST JOHNSBURY
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05819-2646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-274-6400
-----------------------------------------------------
Fax | 877-681-3291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4141
-----------------------------------------------------
City | ST JOHNSBURY
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05819-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-274-6400
-----------------------------------------------------
Fax | 877-681-3291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | SARA DEMETRY
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 802-274-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------