Provider Demographics
NPI:1477088532
Name:GILBERT, PERIDOT (PLPC)
Entity Type:Individual
Prefix:MRS
First Name:PERIDOT
Middle Name:
Last Name:GILBERT
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 AIRLINE DR APT 31B
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6642
Mailing Address - Country:US
Mailing Address - Phone:318-349-7665
Mailing Address - Fax:
Practice Address - Street 1:520 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2312
Practice Address - Country:US
Practice Address - Phone:318-349-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6951101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor