Provider Demographics
NPI:1528141967
Name:ELLERY, NANCY JEAN (LICSW)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JEAN
Last Name:ELLERY
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 1:64 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4554
Mailing Address - Country:US
Mailing Address - Phone:802-747-7296
Mailing Address - Fax:802-773-3965
Practice Address - Street 1:64 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4554
Practice Address - Country:US
Practice Address - Phone:802-747-7296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0000259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1157Medicaid
VT18144OtherBLUE CROSS
VT18144OtherBLUE CROSS