Provider Demographics
NPI:1275763021
Name:GORDON, KIM MARCUS (LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARCUS
Last Name:GORDON
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 1:113 HERRING DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-1113
Mailing Address - Country:US
Mailing Address - Phone:504-319-8247
Mailing Address - Fax:
Practice Address - Street 1:2800 GAUSE BLVD E
Practice Address - Street 2:SUITE B
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4247
Practice Address - Country:US
Practice Address - Phone:504-319-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical