Provider Demographics
NPI:1558067637
Name:GORDON, SHANNON SUZETTE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SUZETTE
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:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-1084
Mailing Address - Country:US
Mailing Address - Phone:980-318-6915
Mailing Address - Fax:
Practice Address - Street 1:213 PATTON DR STE B
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4696
Practice Address - Country:US
Practice Address - Phone:980-465-2533
Practice Address - Fax:704-419-2065
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP018665101Y00000X, 101YM0800X, 101YP2500X, 1041C0700X
P0186651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional