Provider Demographics
NPI:1063652543
Name:GORDON, STEVEN D (LADC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:GORDON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1916
Mailing Address - Country:US
Mailing Address - Phone:651-248-0649
Mailing Address - Fax:701-277-0306
Practice Address - Street 1:4227 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2018
Practice Address - Country:US
Practice Address - Phone:701-282-6561
Practice Address - Fax:701-277-0306
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300757101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)