Healthcare Provider Details

I. General information

NPI: 1376369264
Provider Name (Legal Business Name): NICOLE DE LA FUENTE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N CARROLLTON AVE
NEW ORLEANS LA
70119-4700
US

IV. Provider business mailing address

1466 CRESCENT DR
NEW ORLEANS LA
70122-2008
US

V. Phone/Fax

Practice location:
  • Phone: 504-434-2114
  • Fax:
Mailing address:
  • Phone: 409-656-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15478
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: