Provider Demographics
NPI:1982181749
Name:GORDON, LAINE MAREN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAINE
Middle Name:MAREN
Last Name:GORDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8317 CHASEWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-5608
Mailing Address - Country:US
Mailing Address - Phone:701-741-2809
Mailing Address - Fax:
Practice Address - Street 1:1599 J ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS AFB
Practice Address - State:ND
Practice Address - Zip Code:58205-6306
Practice Address - Country:US
Practice Address - Phone:701-747-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099251841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical