Provider Demographics
NPI:1376030122
Name:GORDON, SUSAN ELIZABETH (LCADC-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCADC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4541
Mailing Address - Country:US
Mailing Address - Phone:667-600-3310
Mailing Address - Fax:667-600-4060
Practice Address - Street 1:300 W 9TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4541
Practice Address - Country:US
Practice Address - Phone:667-600-3310
Practice Address - Fax:667-600-4060
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA-348101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)