Provider Demographics
NPI:1548355928
Name:GAUDREAULT, ELSIE ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:ELSIE
Middle Name:ANN
Last Name:GAUDREAULT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:GAUDREAULT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:6055 MONTE VISTA LN
Mailing Address - Street 2:932
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-5419
Mailing Address - Country:US
Mailing Address - Phone:817-240-7883
Mailing Address - Fax:817-922-1076
Practice Address - Street 1:3905 GABLE LN
Practice Address - Street 2:723
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-2829
Practice Address - Country:US
Practice Address - Phone:817-240-7883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3905 723OtherHOME ADDRESS NUMBERS