Provider Demographics
NPI:1316284276
Name:VICELLIO, DANA LETARD (EDS, LPC,)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LETARD
Last Name:VICELLIO
Suffix:
Gender:F
Credentials:EDS, LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 PRIDE PORT HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7462
Mailing Address - Country:US
Mailing Address - Phone:225-324-8934
Mailing Address - Fax:
Practice Address - Street 1:7600 PRIDE PORT HUDSON RD
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7462
Practice Address - Country:US
Practice Address - Phone:225-324-8934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-12
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3581OtherLICENSE