Provider Demographics
NPI:1154574796
Name:DEBARGE, MILDRED V (LAC)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:V
Last Name:DEBARGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 W PRIEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8360
Mailing Address - Country:US
Mailing Address - Phone:337-475-2557
Mailing Address - Fax:337-266-5157
Practice Address - Street 1:1709 W PRIEN LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8360
Practice Address - Country:US
Practice Address - Phone:337-475-2557
Practice Address - Fax:337-266-5157
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)