Provider Demographics
NPI:1669439352
Name:GORDON, JAMES BLAKELY (MRC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BLAKELY
Last Name:GORDON
Suffix:
Gender:M
Credentials:MRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COLONIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-2219
Mailing Address - Country:US
Mailing Address - Phone:803-898-1555
Mailing Address - Fax:803-898-2194
Practice Address - Street 1:1821 PICKENS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2630
Practice Address - Country:US
Practice Address - Phone:803-929-1234
Practice Address - Fax:803-929-1247
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC#4691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health