Healthcare Provider Details

I. General information

NPI: 1528171279
Provider Name (Legal Business Name): VICKI G CANNELLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEADOW LANE CENTRAL LOUISIANA STATE HOSPITAL UNIT 6
PINEVILLE LA
71306-0118
US

IV. Provider business mailing address

UNIT 6 MEADOW LANE C/O CENTRAL LA STATE HOSPITAL
PINEVILLE MO
71360
US

V. Phone/Fax

Practice location:
  • Phone: 318-484-6400
  • Fax: 318-487-5703
Mailing address:
  • Phone: 660-890-8186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLA 2012
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: