Provider Demographics
NPI:1346279551
Name:PALOMBO, MICHAEL B (LICSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:PALOMBO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:SUITE 3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:802-488-6900
Mailing Address - Fax:
Practice Address - Street 1:300 FLYNN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5301
Practice Address - Country:US
Practice Address - Phone:802-488-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00000561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007285Medicaid