MEDICARE: MARLO GAZZO SHEPARD 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	0494	MS
2	106H00000X	Marriage & Family Therapist	MFT1340	LA

General Provider Information

NPI Number	:	1669200994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLO GAZZO SHEPARD LMFT

Provider Business Mailing Address
First Line	:	PO BOX 87
Second Line	:
City	:	OAK RIDGE
State	:	LA
Zip	:	71264-0087
Country	:	US
Telephone Number	:	318-381-7713
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 HOLLY STREET
Second Line	:
City	:	OAK RIDGE
State	:	LA
Zip	:	71264
Country	:	US
Telephone Number	:	318-381-7133
Fax Number	:

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

Provider Enumeration Date	:	07/26/2024
Last Update Date	:	07/26/2024

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