Provider Demographics
NPI:1568761989
Name:GORDON, TARNISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:TARNISHA
Middle Name:
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 1:49504 LABAERE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1794
Mailing Address - Country:US
Mailing Address - Phone:850-339-4964
Mailing Address - Fax:
Practice Address - Street 1:49504 LABAERE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1794
Practice Address - Country:US
Practice Address - Phone:850-339-4964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0043521041C0700X
NCC0085011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical