Basic Information
| Provider Information | |||||||||
| NPI: | 1790090256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANNELL | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VENEZIA | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1316 SOMERVILLE RD SE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356014305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563556091 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4110 US HIGHWAY 31 S | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356031644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563556091 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2296C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 51112654 | 01 | AL | BLUE CROSS BLUE SHIELD OF AL | OTHER |