Basic Information
| Provider Information | |||||||||
| NPI: | 1376030122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCADC-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6676003310 | ||||||||
| FaxNumber: | 6676004060 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6676003310 | ||||||||
| FaxNumber: | 6676004060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCA-348 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.