Healthcare Provider Details

I. General information

NPI: 1184356776
Provider Name (Legal Business Name): 27TH AVENUE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 POYDRAS ST SUITE 1400 PMB0879
NEW ORLEANS LA
70130-6116
US

IV. Provider business mailing address

650 POYDRAS ST SUITE 1400 PMB0879
NEW ORLEANS LA
70130-6116
US

V. Phone/Fax

Practice location:
  • Phone: 504-321-1751
  • Fax: 877-479-2005
Mailing address:
  • Phone: 504-321-1751
  • Fax: 877-479-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MASHANNA GALLO
Title or Position: OWNER
Credential: LPC
Phone: 504-321-1751