Provider Demographics
NPI:1760048714
Name:GOSSOU, KOMLANTSE MEDAKPE (LBA)
Entity Type:Individual
Prefix:
First Name:KOMLANTSE
Middle Name:MEDAKPE
Last Name:GOSSOU
Suffix:
Gender:M
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2141
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0268
Mailing Address - Country:US
Mailing Address - Phone:514-243-1354
Mailing Address - Fax:
Practice Address - Street 1:376 MARGARET ST APT B-21
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-5015
Practice Address - Country:US
Practice Address - Phone:514-243-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000169103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst