Provider Demographics
NPI:1710635206
Name:GORDON, TRACY LEATRICE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEATRICE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16701 MELFORD BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4411
Mailing Address - Country:US
Mailing Address - Phone:415-424-4266
Mailing Address - Fax:415-520-6633
Practice Address - Street 1:40 ADELAIDE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-1931
Practice Address - Country:US
Practice Address - Phone:609-273-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040137731041C0700X
MD288991041C0700X
NH27951041C0700X
FLSW201131041C0700X
NV10146-C1041C0700X
NJ44SC060419001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical