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NPI Code Detail

MEDICARE: SHELBY GORDON LBA

MEDICARE: SHELBY GORDON LBA
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
1103K00000XBehavior AnalystL-597LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1L-597OTHERLALBA LICENSE

General Provider Information

NPI Number : 1518628908
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHELBY GORDON LBA
Provider Business Mailing Address
First Line : 3420 NE EVANGELINE TRWY
Second Line :
City : LAFAYETTE
State : LA
Zip : 70507-2554
Country : US
Telephone Number : 337-534-8679
Fax Number : 337-534-0027
Provider Business Practice Location Address
First Line : 3420 NE EVANGELINE TRWY
Second Line :
City : LAFAYETTE
State : LA
Zip : 70507-2554
Country : US
Telephone Number : 337-534-8679
Fax Number : 337-534-0027
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/07/2022
Last Update Date : 01/07/2022

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Directions to “ SHELBY GORDON LBA” Practice Location

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