Basic Information
| Provider Information | |||||||||
| NPI: | 1528100260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | JANINE | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 ALLEN ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027724414 | ||||||||
| FaxNumber: | 8027727973 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 ROUTE 30 N | ||||||||
| Address2: | |||||||||
| City: | BOMOSEEN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057329647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024685641 | ||||||||
| FaxNumber: | 8024682923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 089-0000979 | VT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1010436 | 05 | VT | MEDICAID |