Provider Demographics
NPI:1316683758
Name:MAVYN, DRIFT E (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:DRIFT
Middle Name:E
Last Name:MAVYN
Suffix:
Gender:X
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:DRIFT
Other - Middle Name:
Other - Last Name:MAVYN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-0157
Mailing Address - Country:US
Mailing Address - Phone:802-321-5066
Mailing Address - Fax:802-210-3972
Practice Address - Street 1:74 GRAFTON RD.
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353
Practice Address - Country:US
Practice Address - Phone:802-321-5066
Practice Address - Fax:802-210-3972
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01346301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT5212947OtherBCBS VERMONT
VT6712069Medicaid
VTMVP0551OtherMVP INSURANCE