Provider Demographics
NPI:1316012784
Name:GORDON, MARY ELAINE (LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELAINE
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CA
Mailing Address - Zip Code:95938
Mailing Address - Country:US
Mailing Address - Phone:530-521-6616
Mailing Address - Fax:
Practice Address - Street 1:3 WILLIAMSBURG LN
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926
Practice Address - Country:US
Practice Address - Phone:530-521-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT41065106H00000X
CARN318306163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA41065OtherMFC
CA41065OtherMFC