MEDICARE: MR. MICHEL GEORGE VANGORDON MA, LMFT

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	106H00000X	Marriage & Family Therapist	MFC36265	CA

General Provider Information

NPI Number	:	1649494345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHEL GEORGE VANGORDON MA, LMFT

Provider Business Mailing Address
First Line	:	PO BOX 10063
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96158-3063
Country	:	US
Telephone Number	:	530-318-1502
Fax Number	:

Provider Business Practice Location Address
First Line	:	3351 LAKE TAHOE BLVD STE 9
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-7920
Country	:	US
Telephone Number	:	530-318-1502
Fax Number	:	530-600-3866

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	01/19/2017

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