Provider Demographics
NPI:1891032447
Name:GORDON, LORRAINE
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
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 148
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-0148
Mailing Address - Country:US
Mailing Address - Phone:605-224-5811
Mailing Address - Fax:605-224-6921
Practice Address - Street 1:803 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3312
Practice Address - Country:US
Practice Address - Phone:605-224-5811
Practice Address - Fax:605-224-6921
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health