Provider Demographics
NPI:1124118302
Name:OWEN, CAROL ELISSA (LICSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELISSA
Last Name:OWEN
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:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:THETFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05074-0015
Mailing Address - Country:US
Mailing Address - Phone:207-779-7635
Mailing Address - Fax:978-356-2015
Practice Address - Street 1:28 LAKE MOREY RD APT 2
Practice Address - Street 2:
Practice Address - City:FAIRLEE
Practice Address - State:VT
Practice Address - Zip Code:05045-9824
Practice Address - Country:US
Practice Address - Phone:207-779-7635
Practice Address - Fax:207-779-7635
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01350721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty