Provider Demographics
NPI:1083704084
Name:GORDON, LAURA J (LLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:GORDON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12851 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-8506
Mailing Address - Country:US
Mailing Address - Phone:810-227-1211
Mailing Address - Fax:810-220-5509
Practice Address - Street 1:12851 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-8506
Practice Address - Country:US
Practice Address - Phone:810-227-1211
Practice Address - Fax:810-220-5509
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006382103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist