Healthcare Provider Details

I. General information

NPI: 1922369297
Provider Name (Legal Business Name): NORTHLAKE COUNSELING AND CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S 8TH ST
PONCHATOULA LA
70454-3415
US

IV. Provider business mailing address

902 C M FAGAN DR UNIT B
HAMMOND LA
70403-6043
US

V. Phone/Fax

Practice location:
  • Phone: 985-687-5226
  • Fax: 866-657-7188
Mailing address:
  • Phone: 985-687-5226
  • Fax: 866-657-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2753
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1123
License Number StateLA

VIII. Authorized Official

Name: MISS JESSICA G GANDOLFO
Title or Position: OWNER
Credential: LPC, LMFT
Phone: 985-687-5226