Provider Demographics
NPI:1841774676
Name:GORDON-SHIRLEY, CAROL ANN (LICDC-CS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:GORDON-SHIRLEY
Suffix:
Gender:F
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 GLENCROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-3361
Mailing Address - Country:US
Mailing Address - Phone:513-827-9044
Mailing Address - Fax:513-832-1332
Practice Address - Street 1:5122 GLENCROSSING WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3361
Practice Address - Country:US
Practice Address - Phone:513-827-9044
Practice Address - Fax:513-832-1332
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700610104100000X
OHLICDC.161496101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker