MEDICARE: MS. CONSUELA MARIE COLSTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	5646	LA
2	104100000X	Social Worker	5646	LA
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	5646	LA

General Provider Information

NPI Number	:	1013295559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONSUELA MARIE COLSTON LCSW

Provider Business Mailing Address
First Line	:	2009 GRIFFIN ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-1411
Country	:	US
Telephone Number	:	337-377-8008
Fax Number	:	337-326-4443

Provider Business Practice Location Address
First Line	:	2009 GRIFFIN ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-1411
Country	:	US
Telephone Number	:	337-377-8008
Fax Number	:	337-326-4443

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	08/06/2024

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