Provider Demographics
NPI:1255670287
Name:GORDON, AMANDA B (LCPC, CD(DONA))
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCPC, CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 W. FULLERTON
Mailing Address - Street 2:#305
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-304-6483
Mailing Address - Fax:
Practice Address - Street 1:1350 W FULLERTON AVE
Practice Address - Street 2:#305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2198
Practice Address - Country:US
Practice Address - Phone:773-304-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007445101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health