Provider Demographics
NPI:1164538336
Name:ZANCANELLA, CAROL A (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:ZANCANELLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:ZANCANELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LLC
Mailing Address - Street 1:965 SW EMKAY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3598
Mailing Address - Country:US
Mailing Address - Phone:541-410-4374
Mailing Address - Fax:541-678-5972
Practice Address - Street 1:965 SW EMKAY DR STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3598
Practice Address - Country:US
Practice Address - Phone:541-410-4374
Practice Address - Fax:541-678-5972
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL26381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR162950Medicare PIN