Provider Demographics
NPI:1528171279
Name:CANNELLA, VICKI G (LCSW)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:G
Last Name:CANNELLA
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:UNIT 6 MEADOW LANE
Mailing Address - Street 2:C/O CENTRAL LA STATE HOSPITAL
Mailing Address - City:PINEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:71360
Mailing Address - Country:US
Mailing Address - Phone:660-890-8186
Mailing Address - Fax:
Practice Address - Street 1:MEADOW LANE
Practice Address - Street 2:CENTRAL LOUISIANA STATE HOSPITAL UNIT 6
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71306-0118
Practice Address - Country:US
Practice Address - Phone:318-484-6400
Practice Address - Fax:318-487-5703
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 20121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical