MEDICARE: MR. TAGE ALAN LILJA MSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	089.0106322	VT

General Provider Information

NPI Number	:	1780827147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TAGE ALAN LILJA MSW, LICSW

Provider Business Mailing Address
First Line	:	391 SOUTHWIND RD
Second Line	:
City	:	HINESBURG
State	:	VT
Zip	:	05461-4448
Country	:	US
Telephone Number	:	802-391-9865
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 SAINT PAUL ST STE 107
Second Line	:
City	:	BURLINGTON
State	:	VT
Zip	:	05401-8462
Country	:	US
Telephone Number	:	802-391-9865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2009
Last Update Date	:	07/30/2019

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