Provider Demographics
NPI:1134135387
Name:GORDH, LYN (LCSW)
Entity Type:Individual
Prefix:
First Name:LYN
Middle Name:
Last Name:GORDH
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 1:6602 GRAND TETON PLZ
Mailing Address - Street 2:STE. 100
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1091
Mailing Address - Country:US
Mailing Address - Phone:608-828-3636
Mailing Address - Fax:608-828-3637
Practice Address - Street 1:6602 GRAND TETON PLZ.
Practice Address - Street 2:STE. 100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2905
Practice Address - Country:US
Practice Address - Phone:608-828-3636
Practice Address - Fax:608-828-3637
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI798-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39593700Medicaid
WI39593700Medicaid