Healthcare Provider Details

I. General information

NPI: 1104646835
Provider Name (Legal Business Name): SYDNEY PAGE GORDON MMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1799 STUMPF BLVD
TERRYTOWN LA
70056-3950
US

IV. Provider business mailing address

4530 14TH ST
MARRERO LA
70072-3861
US

V. Phone/Fax

Practice location:
  • Phone: 504-656-4325
  • Fax:
Mailing address:
  • Phone: 504-715-1193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberPLM1554
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: