Provider Demographics
NPI:1790264901
Name:GORDON-THOMAS, OLIVIA R
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:R
Last Name:GORDON-THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:OLIVIA
Other - Middle Name:R
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:318 BRIDGEWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4351
Mailing Address - Country:US
Mailing Address - Phone:678-807-9594
Mailing Address - Fax:
Practice Address - Street 1:230 S CULVER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4806
Practice Address - Country:US
Practice Address - Phone:678-807-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional