=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275957979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHLAKE COUNSELING AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2014
-----------------------------------------------------
Last Update Date | 02/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 C M FAGAN DR STE B
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70403-6043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-687-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 485 S 8TH ST
-----------------------------------------------------
City | PONCHATOULA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70454-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-687-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA GANDOLFO
-----------------------------------------------------
Credential | LPC-S, LMFT
-----------------------------------------------------
Telephone | 985-687-5226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2753
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------