Provider Demographics
NPI:1457647174
Name:GORDY, GLORIA J (GLORIA GORDY)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:GORDY
Suffix:
Gender:F
Credentials:GLORIA GORDY
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:J
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GLORIA GORDY
Mailing Address - Street 1:8401 LINK HILLS LOOP
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3246
Mailing Address - Country:US
Mailing Address - Phone:571-248-2496
Mailing Address - Fax:
Practice Address - Street 1:8550 LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1515
Practice Address - Country:US
Practice Address - Phone:301-816-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000705101YA0400X, 103TP2701X
VA0001120029163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No163W00000XNursing Service ProvidersRegistered Nurse