Provider Demographics
NPI:1952641789
Name:GORDON, COLEMAN (MHPP)
Entity Type:Individual
Prefix:
First Name:COLEMAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:COLE
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QBHP
Mailing Address - Street 1:4171 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4591
Mailing Address - Country:US
Mailing Address - Phone:479-521-1427
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:701 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2105
Practice Address - Country:US
Practice Address - Phone:870-772-5028
Practice Address - Fax:870-772-5056
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator