1699711655 NPI number — PAIGE F VANDERLICK LCSW

Table of content: PAIGE F VANDERLICK LCSW (NPI 1699711655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699711655 NPI number — PAIGE F VANDERLICK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERLICK
Provider First Name:
PAIGE
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699711655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 YORKTOWN DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71303-3621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-487-9895
Provider Business Mailing Address Fax Number:
318-767-3339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 YORKTOWN DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71303-3621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-487-9895
Provider Business Practice Location Address Fax Number:
318-767-3339
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3617 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1655635 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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