Provider Demographics
NPI:1194801555
Name:COSTILLA, ANGELA MONCEAUX (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MONCEAUX
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 JOHNSTON ST # 549
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3243
Mailing Address - Country:US
Mailing Address - Phone:337-356-7924
Mailing Address - Fax:
Practice Address - Street 1:302 DULLES DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3008
Practice Address - Country:US
Practice Address - Phone:337-262-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2015-02-25
Deactivation Date:2011-12-28
Deactivation Code:
Reactivation Date:2015-02-17
Provider Licenses
StateLicense IDTaxonomies
LA45651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical