Provider Demographics
NPI:1124894787
Name:KANNER, NATALIE TARA
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:TARA
Last Name:KANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:TARA
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-0433
Mailing Address - Country:US
Mailing Address - Phone:978-852-4933
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE RD STE 450
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7780
Practice Address - Country:US
Practice Address - Phone:802-922-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01356231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical