Provider Demographics
NPI:1528280682
Name:MILLWOOD, MOLLY CAROLINE (PHD)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:CAROLINE
Last Name:MILLWOOD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:CAROLINE MILLWOOD
Other - Last Name:KIRSHENBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1 WINOOSKI PARK
Mailing Address - Street 2:BOX 122
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05439-0001
Mailing Address - Country:US
Mailing Address - Phone:802-578-4367
Mailing Address - Fax:
Practice Address - Street 1:29 ETHAN ALLEN AVE
Practice Address - Street 2:SUITE 326B
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05439-0001
Practice Address - Country:US
Practice Address - Phone:802-578-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT842103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011275Medicaid
VT915 00068518OtherBCBS OF VERMONT PROVIDER#