Provider Demographics
NPI:1104206630
Name:GORDON, CIMENA (LICSW)
Entity Type:Individual
Prefix:
First Name:CIMENA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7903
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-0903
Mailing Address - Country:US
Mailing Address - Phone:651-224-2172
Mailing Address - Fax:
Practice Address - Street 1:2277 HIGHWAY 36 W
Practice Address - Street 2:SUITE 310
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3804
Practice Address - Country:US
Practice Address - Phone:651-224-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN164861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical