Provider Demographics
NPI:1912471335
Name:THERIOT, DENA MASON (LCSW-BACS)
Entity type:Individual
Prefix:
First Name:DENA
Middle Name:MASON
Last Name:THERIOT
Suffix:
Gender:F
Credentials:LCSW-BACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 PONTCHARTRAIN DR APT N
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-5546
Mailing Address - Country:US
Mailing Address - Phone:504-259-6724
Mailing Address - Fax:
Practice Address - Street 1:620 OAK HARBOR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8862
Practice Address - Country:US
Practice Address - Phone:504-259-6724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA32821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical