Provider Demographics
NPI:1518982362
Name:GORDON, CAROL EVELYN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:EVELYN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9443 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1105
Mailing Address - Country:US
Mailing Address - Phone:847-677-9187
Mailing Address - Fax:847-677-9176
Practice Address - Street 1:9443 DRAKE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1105
Practice Address - Country:US
Practice Address - Phone:847-677-9187
Practice Address - Fax:847-677-9176
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490014731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL800006567OtherRAILROAD MEDICARE
IL935300Medicare ID - Type Unspecified