Provider Demographics
NPI:1891377941
Name:GORDON, ELIZABETH J
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
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 1180
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-1180
Mailing Address - Country:US
Mailing Address - Phone:720-442-1999
Mailing Address - Fax:
Practice Address - Street 1:1008 E BADGER RD
Practice Address - Street 2:
Practice Address - City:CRESTONE
Practice Address - State:CO
Practice Address - Zip Code:81131
Practice Address - Country:US
Practice Address - Phone:720-442-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health