Provider Demographics
NPI:1538453121
Name:GORDON, LAURIE ANNE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANNE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 HOLLOW PINE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6161
Mailing Address - Country:US
Mailing Address - Phone:407-257-0072
Mailing Address - Fax:407-257-0072
Practice Address - Street 1:1109 HOLLOW PINE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6161
Practice Address - Country:US
Practice Address - Phone:407-257-0072
Practice Address - Fax:407-257-0072
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor