Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 984 | LA |
Y | 103TC0700X | Clinical Psychologist | 984 | LA |
NPI | 1003875246 |
---|---|
Provider Name | Dr. Elsie Managbanag Gordon |
First Address | West Monroe, LA 71291-8316 |
Second Address | West Monroe, LA 71291-8316 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1721301 | (05) | LA |