Provider Demographics
NPI:1588800882
Name:GORDER, COREY JAMES (LPCC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:JAMES
Last Name:GORDER
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10275 SJULE RD
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-7009
Mailing Address - Country:US
Mailing Address - Phone:701-201-0076
Mailing Address - Fax:
Practice Address - Street 1:104 11TH ST W
Practice Address - Street 2:STE. 4
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-2005
Practice Address - Country:US
Practice Address - Phone:701-201-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND569-12-15-06-190101Y00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054517Medicaid
ND1225448798Medicaid
ND1588800882OtherBLUE CROSS/BLUE SHIELD