Provider Demographics
NPI:1003296062
Name:GORDON, SHAINA
Entity Type:Individual
Prefix:
First Name:SHAINA
Middle Name:
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 1:980 SAINT CHARLES AVE NE
Mailing Address - Street 2:#3
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4263
Mailing Address - Country:US
Mailing Address - Phone:954-895-1453
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY
Practice Address - Street 2:221
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1753
Practice Address - Country:US
Practice Address - Phone:404-292-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW005234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health