Provider Demographics
NPI:1285708644
Name:TRAILWEAVER, REGINA DENISE (LICSW)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:DENISE
Last Name:TRAILWEAVER
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 1:342 VT ROUTE 100
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05748
Mailing Address - Country:US
Mailing Address - Phone:802-767-9263
Mailing Address - Fax:
Practice Address - Street 1:128 MERCHANTS ROW RM 605
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5909
Practice Address - Country:US
Practice Address - Phone:802-773-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00007231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007305Medicaid