Provider Demographics
NPI:1740602127
Name:GORDON, REBECCA BAKER
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:BAKER
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1019
Practice Address - Country:US
Practice Address - Phone:606-743-3139
Practice Address - Fax:606-743-4336
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid