Provider Demographics
NPI:1699711655
Name:VANDERLICK, PAIGE F (LCSW)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:F
Last Name:VANDERLICK
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 1:109 YORKTOWN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3621
Mailing Address - Country:US
Mailing Address - Phone:318-487-9895
Mailing Address - Fax:318-767-3339
Practice Address - Street 1:109 YORKTOWN DR
Practice Address - Street 2:SUITE B
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3621
Practice Address - Country:US
Practice Address - Phone:318-487-9895
Practice Address - Fax:318-767-3339
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA36171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1655635Medicaid
LA5T603Medicare ID - Type Unspecified