Provider Demographics
NPI:1780988097
Name:EARTHLY, THERESA LAVELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LAVELLE
Last Name:EARTHLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:LAVELLE
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1217 WILLOW GLEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-5454
Mailing Address - Country:US
Mailing Address - Phone:318-487-4400
Mailing Address - Fax:318-487-0525
Practice Address - Street 1:1217 WILLOW GLEN RIVER RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-5454
Practice Address - Country:US
Practice Address - Phone:318-487-4400
Practice Address - Fax:318-487-0525
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA24761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical