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NPI Code Detail

MEDICARE: MRS. THERESA LAVELLE EARTHLY LCSW

MEDICARE: MRS. THERESA LAVELLE EARTHLY 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
11041C0700XClinical Social Worker2476LA

General Provider Information

NPI Number : 1780988097
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. THERESA LAVELLE EARTHLY LCSW
Provider Business Mailing Address
First Line : 1217 WILLOW GLEN RIVER RD
Second Line :
City : ALEXANDRIA
State : LA
Zip : 71302-5454
Country : US
Telephone Number : 318-487-4400
Fax Number : 318-487-0525
Provider Business Practice Location Address
First Line : 1217 WILLOW GLEN RIVER RD
Second Line :
City : ALEXANDRIA
State : LA
Zip : 71302-5454
Country : US
Telephone Number : 318-487-4400
Fax Number : 318-487-0525
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/29/2010
Last Update Date : 12/29/2010

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