Provider Demographics
NPI:1649589771
Name:SPILLMAN, BRENNA LAKAYE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:BRENNA
Middle Name:LAKAYE
Last Name:SPILLMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:BRENNA
Other - Middle Name:LAKAYE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2116 N BOLTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-4405
Mailing Address - Country:US
Mailing Address - Phone:318-445-1250
Mailing Address - Fax:318-445-1493
Practice Address - Street 1:2116 N BOLTON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-4405
Practice Address - Country:US
Practice Address - Phone:318-445-1250
Practice Address - Fax:318-445-1493
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01292101YA0400X
LA1292101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)