Provider Demographics
NPI:1104903319
Name:BOYD, MARY ANN DATTILO (LICSW)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:DATTILO
Last Name:BOYD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 LOWER NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-5210
Mailing Address - Country:US
Mailing Address - Phone:802-349-6182
Mailing Address - Fax:
Practice Address - Street 1:135 S PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1479
Practice Address - Country:US
Practice Address - Phone:802-349-6182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900010581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical