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General NPI Number Information
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NPI Number | 1649494345
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Entity Type | Individual
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Provider Name | MICHEL GEORGE VANGORDON MA, LMFT
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Gender | Male
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 01/19/2017
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Provider Practice Location Address
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Address Line | 3351 LAKE TAHOE BLVD STE 9
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-7920
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Country | US
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Telephone | 530-318-1502
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Fax | 530-600-3866
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Provider Business Mailing Address
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Address Line | PO BOX 10063
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96158-3063
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Country | US
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Telephone | 530-318-1502
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC36265
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License Number State | CA
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