Provider Demographics
NPI:1851752224
Name:KELLY-GORDON, NICOLE ANGELA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANGELA
Last Name:KELLY-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 1:5240 E IDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-8719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 W ROSE GARDEN LN STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3135
Practice Address - Country:US
Practice Address - Phone:623-265-7215
Practice Address - Fax:833-465-1462
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-159331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123528Medicaid
AZ123528Medicaid