Provider Demographics
NPI:1902303399
Name:GOVERNOR, CEDRIC JEROME (BS PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:JEROME
Last Name:GOVERNOR
Suffix:
Gender:M
Credentials:BS PSYCHOLOGY
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2540 SEVERN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-5941
Mailing Address - Country:US
Mailing Address - Phone:504-454-3740
Mailing Address - Fax:504-454-3738
Practice Address - Street 1:2540 SEVERN AVE STE 100
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-5941
Practice Address - Country:US
Practice Address - Phone:504-454-3740
Practice Address - Fax:504-454-3738
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YM0800XMedicaid