Healthcare Provider Details

I. General information

NPI: 1275252348
Provider Name (Legal Business Name): VITALITY ADDICTION SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S LEWIS ST
NEW IBERIA LA
70560-4820
US

IV. Provider business mailing address

PO BOX 82599
LAFAYETTE LA
70598-2599
US

V. Phone/Fax

Practice location:
  • Phone: 337-465-1195
  • Fax:
Mailing address:
  • Phone: 337-288-1908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LESLEY SHERMAN
Title or Position: MEMBER
Credential: RN
Phone: 225-329-6783