Provider Demographics
NPI:1619309945
Name:GORDON, STEPHANIE JEAN (LAC, MSTOM)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JEAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WABASH ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3334
Mailing Address - Country:US
Mailing Address - Phone:219-262-2670
Mailing Address - Fax:
Practice Address - Street 1:410 WABASH ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3334
Practice Address - Country:US
Practice Address - Phone:219-262-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374J00000X
IN84000170A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No374J00000XNursing Service Related ProvidersDoula