Healthcare Provider Details

I. General information

NPI: 1013295559
Provider Name (Legal Business Name): CONSUELA MARIE COLSTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 GRIFFIN ST
LAKE CHARLES LA
70601-1411
US

IV. Provider business mailing address

2009 GRIFFIN ST
LAKE CHARLES LA
70601-1411
US

V. Phone/Fax

Practice location:
  • Phone: 337-377-8008
  • Fax: 337-326-4443
Mailing address:
  • Phone: 337-377-8008
  • Fax: 337-326-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number5646
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5646
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5646
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: