Provider Demographics
NPI:1174027825
Name:LUSH, VANISE (BA)
Entity Type:Individual
Prefix:MS
First Name:VANISE
Middle Name:
Last Name:LUSH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 KIMBROUGH BLVD BLDG Q
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-4307
Mailing Address - Country:US
Mailing Address - Phone:318-574-4400
Mailing Address - Fax:318-574-4407
Practice Address - Street 1:124 KIMBROUGH BLVD BLDG Q
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-4307
Practice Address - Country:US
Practice Address - Phone:318-574-4400
Practice Address - Fax:318-574-4407
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor