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NPI Code Detail

MEDICARE: MS. ELISE BROKAW LICSW

MEDICARE: MS. ELISE BROKAW 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
11041C0700XClinical Social Worker0890001032VT

General Provider Information

NPI Number : 1982060885
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ELISE BROKAW LICSW
Provider Business Mailing Address
First Line : 89 MAIN ST
Second Line :
City : MIDDLEBURY
State : VT
Zip : 05753-1459
Country : US
Telephone Number : 802-388-6751
Fax Number : 802-388-8183
Provider Business Practice Location Address
First Line : 67 CATAMOUNT PARK
Second Line :
City : MIDDLEBURY
State : VT
Zip : 05753-1397
Country : US
Telephone Number : 802-388-6751
Fax Number : 802-388-8183
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/07/2016
Last Update Date : 01/07/2016

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Directions to “ MS. ELISE BROKAW LICSW” Practice Location

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