Basic Information
Provider Information | |||||||||
NPI: | 1578033866 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GORDON | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | PITRE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11861 COURSEY BLVD | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708164404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256128656 | ||||||||
FaxNumber: | 2253418774 | ||||||||
Practice Location | |||||||||
Address1: | 123 CHURCH STREET | ||||||||
Address2: |   | ||||||||
City: | GRAND COUTEAU | ||||||||
State: | LA | ||||||||
PostalCode: | 70541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3376623737 | ||||||||
FaxNumber: | 3376623636 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2018 | ||||||||
LastUpdateDate: | 02/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CIT5128 | LA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | 005670607 | LA | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.