Provider Demographics
NPI:1972036432
Name:BUCKHOLZ, VINCENT (LICSW)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:BUCKHOLZ
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 1:4 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-3535
Mailing Address - Country:US
Mailing Address - Phone:802-376-1665
Mailing Address - Fax:
Practice Address - Street 1:4 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3535
Practice Address - Country:US
Practice Address - Phone:802-376-1665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08901148071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical