Healthcare Provider Details

I. General information

NPI: 1457971046
Provider Name (Legal Business Name): DEBRA LYNN DIFULCO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 COLISEUM BLVD STE A
ALEXANDRIA LA
71303-3993
US

IV. Provider business mailing address

5604 COLISEUM BLVD STE A
ALEXANDRIA LA
71303-3993
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5282
  • Fax: 318-487-5481
Mailing address:
  • Phone: 318-487-5282
  • Fax: 318-487-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3249
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: