Provider Demographics
NPI:1902829682
Name:GORDON, MARIA WILLIS (LISW, LICDC)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:WILLIS
Last Name:GORDON
Suffix:
Gender:F
Credentials:LISW, LICDC
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 9444
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44711-9444
Mailing Address - Country:US
Mailing Address - Phone:330-430-9535
Mailing Address - Fax:330-430-9534
Practice Address - Street 1:1930 FULTON RD NW
Practice Address - Street 2:SUITE 102
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3526
Practice Address - Country:US
Practice Address - Phone:330-430-9535
Practice Address - Fax:330-430-9534
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI5078104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000388720OtherANTHEM BC/BS
OH318639OtherUNITED BEHAVORIAL HEALTH
OH760801293027OtherCARESOURCE
OH80249800OtherMEGELLAN
OH760801293027OtherCARESOURCE