Provider Demographics
NPI:1003485962
Name:GORDON, SHIRLEY L (CAC, CMHT, CPRS)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:CAC, CMHT, CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2402
Mailing Address - Country:US
Mailing Address - Phone:443-949-9545
Mailing Address - Fax:
Practice Address - Street 1:92 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2432
Practice Address - Country:US
Practice Address - Phone:443-949-9545
Practice Address - Fax:240-366-0055
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC101YA0400X, 175T00000X
101YM0800X, 101YA0400X
MD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG635765549569OtherSTATE ISSUED ID