Provider Demographics
NPI:1942387170
Name:GORDON, LAURIE R (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:LMSW
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 43
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0043
Mailing Address - Country:US
Mailing Address - Phone:517-623-6260
Mailing Address - Fax:517-623-6460
Practice Address - Street 1:4463 CRICKET RIDGE DR APT 202
Practice Address - Street 2:202
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-2933
Practice Address - Country:US
Practice Address - Phone:517-281-5718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010348711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008975170OtherBLUE CROSS BLUE SHIELD
MI8008975170OtherBLUE CROSS BLUE SHIELD