Provider Demographics
NPI:1306147517
Name:CASEBOLT, REBA DIANNE (CRC, LAC, CI)
Entity type:Individual
Prefix:MS
First Name:REBA
Middle Name:DIANNE
Last Name:CASEBOLT
Suffix:
Gender:F
Credentials:CRC, LAC, CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13170 DUTCHTOWN POINT AVENUE #914
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-1317
Mailing Address - Country:US
Mailing Address - Phone:504-458-0497
Mailing Address - Fax:800-697-3631
Practice Address - Street 1:13170 DUTCHTWN PT AVE APT 914
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-0104
Practice Address - Country:US
Practice Address - Phone:504-458-0497
Practice Address - Fax:800-697-3631
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC1249101Y00000X
LACRC00109065101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor