Basic Information
| Provider Information | |||||||||
| NPI: | 1902994296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | GERALDINE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20990 LASER LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481789229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484865433 | ||||||||
| FaxNumber: | 2484865433 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 GENOA BUSINESS PARK DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481147367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102202787 | ||||||||
| FaxNumber: | 8102202834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801014040 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.