Provider Demographics
NPI:1760061097
Name:GORDON, CALLIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:
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 1:103 W YUCCA ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-1910
Mailing Address - Country:US
Mailing Address - Phone:817-944-0878
Mailing Address - Fax:
Practice Address - Street 1:103 W YUCCA ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-1910
Practice Address - Country:US
Practice Address - Phone:817-944-0878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional