MEDICARE: HEALTHY AVENUES MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20130196	OTHER	LA	LOUISIANA NURSING LICENSE

General Provider Information

NPI Number	:	1659093847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY AVENUES MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	3303 TULANE AVE BLDG 1
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-7186
Country	:	US
Telephone Number	:	504-377-6628
Fax Number	:	833-907-2256

Provider Business Practice Location Address
First Line	:	3303 TULANE AVE BLDG 1
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-7186
Country	:	US
Telephone Number	:	504-377-6628
Fax Number	:	833-907-2256

Authorized Official
Title or Position	:	OWNER
Name	:	DANIELLE GAUDIN
Credential	:	LPN
Telephone Number	:	504-883-7199

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	07/12/2023

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