Provider Demographics
NPI:1033960059
Name:GORDON, INDREA JANENE
Entity Type:Individual
Prefix:
First Name:INDREA
Middle Name:JANENE
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 1:503 SHARPSTONE BND
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9434
Mailing Address - Country:US
Mailing Address - Phone:337-309-0945
Mailing Address - Fax:
Practice Address - Street 1:503 SHARPSTONE BND
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9434
Practice Address - Country:US
Practice Address - Phone:337-309-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst