Basic Information
| Provider Information | |||||||||
| NPI: | 1528171279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNELLA | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | UNIT 6 MEADOW LANE | ||||||||
| Address2: | C/O CENTRAL LA STATE HOSPITAL | ||||||||
| City: | PINEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 71360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MEADOW LANE | ||||||||
| Address2: | CENTRAL LOUISIANA STATE HOSPITAL UNIT 6 | ||||||||
| City: | PINEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713060118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184846400 | ||||||||
| FaxNumber: | 3184875703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LA 2012 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.