Basic Information
| Provider Information | |||||||||
| NPI: | 1326002155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPART. HEALTH AND HOSPITALS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RED RIVER MEDICALLY SUPPORTED DETOX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7118 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713060118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184846400 | ||||||||
| FaxNumber: | 3184875703 | ||||||||
| Practice Location | |||||||||
| Address1: | C/O CENTRAL STATE HOSPITAL, UNIT 6, MEADOW LANE | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184846400 | ||||||||
| FaxNumber: | 3184875703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANNELLA | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | INPATIENT FACILITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3184846661 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW-BACS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | 162 | LA | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
No ID Information.