1902303399 NPI number — CEDRIC JEROME GOVERNOR BS PSYCHOLOGY

Table of content: CEDRIC JEROME GOVERNOR BS PSYCHOLOGY (NPI 1902303399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902303399 NPI number — CEDRIC JEROME GOVERNOR BS PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOVERNOR
Provider First Name:
CEDRIC
Provider Middle Name:
JEROME
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS PSYCHOLOGY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902303399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2540 SEVERN AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70002-5941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-454-3740
Provider Business Mailing Address Fax Number:
504-454-3738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2540 SEVERN AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70002-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-454-3740
Provider Business Practice Location Address Fax Number:
504-454-3738
Provider Enumeration Date:
04/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101YM0800X , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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