Provider Demographics
NPI:1114936036
Name:GORDON, LORELL CYNTHIA (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:MRS
First Name:LORELL
Middle Name:CYNTHIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MONTFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29816
Mailing Address - Country:US
Mailing Address - Phone:864-578-5069
Mailing Address - Fax:864-578-5068
Practice Address - Street 1:167 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302
Practice Address - Country:US
Practice Address - Phone:864-583-1010
Practice Address - Fax:864-582-6361
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3423101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional