Provider Demographics
NPI:1417957192
Name:MUNN, GORDON LANCE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:LANCE
Last Name:MUNN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 TOWN SQUARE BLVD.
Mailing Address - Street 2:SUITE 200, BUILDING 1A
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040
Mailing Address - Country:US
Mailing Address - Phone:214-804-9262
Mailing Address - Fax:972-495-1863
Practice Address - Street 1:675 TOWN SQUARE BLVD
Practice Address - Street 2:SUITE 200, BUILDING 1A
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040
Practice Address - Country:US
Practice Address - Phone:214-804-9262
Practice Address - Fax:972-495-1863
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2014-06-24
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TX226871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX064284501Medicaid
TX00S93XMedicare ID - Type Unspecified
TX064284501Medicaid