=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437820255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE MICHELLE BARDWELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2021
-----------------------------------------------------
Last Update Date | 11/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 FLAGON LOOP
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71360-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-715-7456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 FLAGON LOOP
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71360-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-715-7456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 8472
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------