Provider Demographics
NPI:1578881421
Name:CARDELLA, PAMELA LASTER (LAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LASTER
Last Name:CARDELLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-9471
Mailing Address - Country:US
Mailing Address - Phone:318-243-2231
Mailing Address - Fax:
Practice Address - Street 1:1742 W KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-9581
Practice Address - Country:US
Practice Address - Phone:318-243-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA000024171100000X
LA0309225700000X
LA1647101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist