Provider Demographics
NPI:1659140465
Name:CISTRUNK, LAQUNANA WILLIAMS (LMSW)
Entity Type:Individual
Prefix:
First Name:LAQUNANA
Middle Name:WILLIAMS
Last Name:CISTRUNK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:
Other - Last Name:CISTRUNK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1 COMMERCE DR STE 106
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1499
Mailing Address - Country:US
Mailing Address - Phone:601-255-1618
Mailing Address - Fax:
Practice Address - Street 1:1 COMMERCE DR STE 106
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1499
Practice Address - Country:US
Practice Address - Phone:601-255-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9550104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker