Provider Demographics
NPI:1073762704
Name:GORDON, KELLY VERONICA (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:VERONICA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18947 JOHN J WILLIAMS HWY UNIT 212
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-4476
Mailing Address - Country:US
Mailing Address - Phone:302-567-8331
Mailing Address - Fax:302-645-5041
Practice Address - Street 1:18947 JOHN J WILLIAMS HWY UNIT 212
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4476
Practice Address - Country:US
Practice Address - Phone:302-567-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00015111041C0700X
MD183381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical