Provider Demographics
NPI:1467725085
Name:VICTORIAN, BERNETTA V (LAC, CCGC)
Entity Type:Individual
Prefix:MS
First Name:BERNETTA
Middle Name:V
Last Name:VICTORIAN
Suffix:
Gender:F
Credentials:LAC, CCGC
Other - Prefix:MRS
Other - First Name:BERNETTA
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, CCGC
Mailing Address - Street 1:220 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5140
Mailing Address - Country:US
Mailing Address - Phone:337-948-0226
Mailing Address - Fax:337-948-0303
Practice Address - Street 1:220 S MARKET ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5140
Practice Address - Country:US
Practice Address - Phone:337-948-0226
Practice Address - Fax:337-948-0303
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACCGC 1005101YP2500X
LALAC 817101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional