Provider Demographics
NPI:1467768697
Name:MCGORDON, ADENA MARIE
Entity Type:Individual
Prefix:
First Name:ADENA
Middle Name:MARIE
Last Name:MCGORDON
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 1:9612 W SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8586
Mailing Address - Country:US
Mailing Address - Phone:602-487-4593
Mailing Address - Fax:
Practice Address - Street 1:9612 W SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8586
Practice Address - Country:US
Practice Address - Phone:602-487-4593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2281572385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child