MEDICARE: DR. LA FAUNE YVETTE GORDON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY14560	CA

General Provider Information

NPI Number	:	1144305996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LA FAUNE YVETTE GORDON PH.D.

Provider Business Mailing Address
First Line	:	1525 AVIATION BLVD # 389
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-2805
Country	:	US
Telephone Number	:	310-281-7359
Fax Number	:

Provider Business Practice Location Address
First Line	:	12829 JARVIS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2243
Country	:	US
Telephone Number	:	310-281-7350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	09/09/2008

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