Provider Demographics
NPI:1578033866
Name:GORDON, TARA PITRE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:PITRE
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 1:11861 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4404
Mailing Address - Country:US
Mailing Address - Phone:225-612-8656
Mailing Address - Fax:225-341-8774
Practice Address - Street 1:123 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:GRAND COUTEAU
Practice Address - State:LA
Practice Address - Zip Code:70541
Practice Address - Country:US
Practice Address - Phone:337-662-3737
Practice Address - Fax:337-662-3636
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT5128101YA0400X
LA005670607171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)