Provider Demographics
NPI:1659956480
Name:GORDON, SAMANTHA (MS, LMFT)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 E SOUTHLAKE BLVD STE L-636
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:954-249-2117
Mailing Address - Fax:
Practice Address - Street 1:2140 E SOUTHLAKE BLVD STE L-636
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6516
Practice Address - Country:US
Practice Address - Phone:817-303-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203759106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist