Basic Information
| Provider Information | |||||||||
| NPI: | 1316342876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALDASSARO | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | ALICE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANFIELD | ||||||||
| OtherFirstName: | VIRGINIA | ||||||||
| OtherMiddleName: | ALICE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 330 N JEFFERSON DAVIS PKWY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701195312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049486880 | ||||||||
| FaxNumber: | 5042784007 | ||||||||
| Practice Location | |||||||||
| Address1: | 54002 HIGHWAY 1062 | ||||||||
| Address2: | |||||||||
| City: | LORANGER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704463538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | 2256831310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2014 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5693 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 5693 | 01 | LA | LICENSURE | OTHER |