Provider Demographics
NPI:1609210459
Name:GORDON, SOPHIA CAMILLE
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:CAMILLE
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 1:9020 CATES WAY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8518
Mailing Address - Country:US
Mailing Address - Phone:405-305-6559
Mailing Address - Fax:
Practice Address - Street 1:11428 E 20TH ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6452
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid