Basic Information
| Provider Information | |||||||||
| NPI: | 1528356474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GORDON COUNSELING AND CASE MANAGEMENT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
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| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176236260 | ||||||||
| FaxNumber: | 5176236460 | ||||||||
| Practice Location | |||||||||
| Address1: | 4463 CRICKET RIDGE DR APT 202 | ||||||||
| Address2: | |||||||||
| City: | HOLT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488422933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172815718 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5172815718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801034871 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8008975170 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |