Provider Demographics
NPI:1588638613
Name:GORDON, DENISE ANN (MSW)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSW
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:254-724-7603
Practice Address - Street 1:4945 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-2008
Practice Address - Country:US
Practice Address - Phone:512-819-0500
Practice Address - Fax:512-819-0520
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000040861041C0700X
TX512571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVAD000Medicare UPIN