Provider Demographics
NPI:1407540677
Name:GORDON, NICOLETTE
Entity Type:Individual
Prefix:MS
First Name:NICOLETTE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PAXTON DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3344
Mailing Address - Country:US
Mailing Address - Phone:770-490-4376
Mailing Address - Fax:
Practice Address - Street 1:2020 PAXTON DR SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3344
Practice Address - Country:US
Practice Address - Phone:770-490-4376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013764101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health