Provider Demographics
NPI:1538762471
Name:GORDON, COLT (LCSW 110973)
Entity type:Individual
Prefix:MR
First Name:COLT
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LCSW 110973
Other - Prefix:
Other - First Name:COLT
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:627 15TH ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3109
Mailing Address - Country:US
Mailing Address - Phone:619-453-5063
Mailing Address - Fax:
Practice Address - Street 1:627 15TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3109
Practice Address - Country:US
Practice Address - Phone:619-453-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15771041C0700X
CA1109731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical