Provider Demographics
NPI:1629076286
Name:GORDON, SANDRA PATTON (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:PATTON
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 1:1013 MUMMA RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WORMLEYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1144
Mailing Address - Country:US
Mailing Address - Phone:717-975-1808
Mailing Address - Fax:717-975-5160
Practice Address - Street 1:1013 MUMMA RD
Practice Address - Street 2:SUITE 302
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1144
Practice Address - Country:US
Practice Address - Phone:717-975-1808
Practice Address - Fax:717-975-5160
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0140191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S94638Medicare UPIN
PA033988Medicare ID - Type Unspecified