MEDICARE: TA TANZANIA LEE-GORDON

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1508350794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TA TANZANIA LEE-GORDON

Provider Business Mailing Address
First Line	:	909 S BROAD ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70125-1421
Country	:	US
Telephone Number	:	504-483-3558
Fax Number	:

Provider Business Practice Location Address
First Line	:	13171 LINDEN ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70128-1564
Country	:	US
Telephone Number	:	504-957-6565
Fax Number	:

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

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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