Provider Demographics
NPI:1336509280
Name:GORDON, TRISTA
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 PATTON ST
Mailing Address - Street 2:
Mailing Address - City:BUNKIE
Mailing Address - State:LA
Mailing Address - Zip Code:71322-2369
Mailing Address - Country:US
Mailing Address - Phone:318-264-4598
Mailing Address - Fax:318-253-2222
Practice Address - Street 1:611 PATTON ST
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-2369
Practice Address - Country:US
Practice Address - Phone:318-264-4598
Practice Address - Fax:318-253-2222
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health