Provider Demographics
NPI:1922459072
Name:GORDON, LATASHA M (LCDC III, OCPSA)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCDC III, OCPSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4900
Mailing Address - Fax:
Practice Address - Street 1:2115 W PARK DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1138
Practice Address - Country:US
Practice Address - Phone:440-989-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOCPSA.161742174400000X
OHC.2305280-TRNE101Y00000X
OHLCDCIII.162487101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor