Provider Demographics
NPI:1427126606
Name:BONI, TERESA (LICSW)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:BONI
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:ONE HOSPITAL COURT
Mailing Address - Street 2:SUITE 410
Mailing Address - City:BELLOWS FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05101
Mailing Address - Country:US
Mailing Address - Phone:802-463-3947
Mailing Address - Fax:802-463-1206
Practice Address - Street 1:51 FAIRVIEW STREET
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301
Practice Address - Country:US
Practice Address - Phone:802-254-7500
Practice Address - Fax:802-254-7501
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0890000210103T00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1332Medicaid
VTOVN1332Medicaid