Provider Demographics
NPI:1275729881
Name:GORDON, SUSAN THERESA (LADC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:THERESA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 11TH ST N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2083
Mailing Address - Country:US
Mailing Address - Phone:218-233-6398
Mailing Address - Fax:
Practice Address - Street 1:4227 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2018
Practice Address - Country:US
Practice Address - Phone:701-282-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301445101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301445OtherLADC