Provider Demographics
NPI:1376831024
Name:DAVIS-GORDON, ANDREA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:DAVIS-GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:401 COURAGE WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5594
Mailing Address - Country:US
Mailing Address - Phone:757-478-1502
Mailing Address - Fax:
Practice Address - Street 1:401 COURAGE WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-5594
Practice Address - Country:US
Practice Address - Phone:757-734-1866
Practice Address - Fax:757-734-1882
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW186121041C0700X
VA09040076131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ38487AMedicaid
VA1871542340Medicaid