Provider Demographics
NPI:1700220233
Name:GORDON, JUDITH L (LPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11898 W GOLDENROD AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2439
Mailing Address - Country:US
Mailing Address - Phone:208-658-9703
Mailing Address - Fax:
Practice Address - Street 1:3288 E PINE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5922
Practice Address - Country:US
Practice Address - Phone:208-888-8887
Practice Address - Fax:208-658-0153
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID178101YP2500X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool