Provider Demographics
NPI:1114576329
Name:GORDON, KAITLYN NICOLE (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:NICOLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MS
Other - First Name:KAITLYN
Other - Middle Name:NICOLE
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:626 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3320
Mailing Address - Country:US
Mailing Address - Phone:443-945-5420
Mailing Address - Fax:
Practice Address - Street 1:626 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3320
Practice Address - Country:US
Practice Address - Phone:410-939-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25407104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker