Provider Demographics
NPI:1376928101
Name:GORDON WELLNESS LLC
Entity Type:Organization
Organization Name:GORDON WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:DORLINE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-534-7840
Mailing Address - Street 1:610 THIMBLE SHOALS BLVD
Mailing Address - Street 2:401-A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2573
Mailing Address - Country:US
Mailing Address - Phone:757-534-7840
Mailing Address - Fax:757-534-7844
Practice Address - Street 1:610 THIMBLE SHOALS BLVD
Practice Address - Street 2:401-A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2573
Practice Address - Country:US
Practice Address - Phone:757-534-7840
Practice Address - Fax:757-534-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904008261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty