Provider Demographics
NPI:1558494757
Name:GORDON, LYNNETTE ANN (LPC, LCAS, CRC)
Entity Type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC, LCAS, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 NORTH GRAHAM HOPEDALE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2992
Mailing Address - Country:US
Mailing Address - Phone:336-513-4200
Mailing Address - Fax:336-513-4449
Practice Address - Street 1:319 NORTH GRAHAM HOPEDALE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2992
Practice Address - Country:US
Practice Address - Phone:336-513-4200
Practice Address - Fax:336-513-4449
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC987101YA0400X
NC4457101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC61003110Medicaid
NC4457OtherLIC PROFESS. COUNSELOR
NC987OtherLIC. CLIN. ADDICTION SPEC