Provider Demographics
NPI:1316594971
Name:MARION, ADA WYNNE
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:WYNNE
Last Name:MARION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LOTUS DR N
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-2808
Mailing Address - Country:US
Mailing Address - Phone:985-626-5203
Mailing Address - Fax:
Practice Address - Street 1:510 LOTUS DR N
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2808
Practice Address - Country:US
Practice Address - Phone:985-626-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical