Provider Demographics
NPI:1376317297
Name:GORDON, NICOLE (MS, ADDC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS, ADDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 BROOK PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1865 OLD RANCH RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80908-4528
Practice Address - Country:US
Practice Address - Phone:719-528-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COADDC.0000410101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)