Healthcare Provider Details

I. General information

NPI: 1134663388
Provider Name (Legal Business Name): BRANDON M. GAUDET M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CONEY DR
ARABI LA
70032-2121
US

IV. Provider business mailing address

67 OLD HICKORY ST
CHALMETTE LA
70043-4525
US

V. Phone/Fax

Practice location:
  • Phone: 504-453-0064
  • Fax:
Mailing address:
  • Phone: 504-453-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: