Healthcare Provider Details

I. General information

NPI: 1831835552
Provider Name (Legal Business Name): GINA ROUSSEL WEAVER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8387 NEWFIELD DR
LIVONIA LA
70755-3605
US

IV. Provider business mailing address

9223 SECTION RD
PORT ALLEN LA
70767-5116
US

V. Phone/Fax

Practice location:
  • Phone: 225-412-0202
  • Fax: 225-412-0366
Mailing address:
  • Phone: 225-505-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9609
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: