Provider Demographics
NPI:1023728896
Name:GORDON, CHANELLE (PHD)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14122 MANDERSON PLZ APT 107
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6296
Mailing Address - Country:US
Mailing Address - Phone:415-294-0872
Mailing Address - Fax:
Practice Address - Street 1:14122 MANDERSON PLZ APT 107
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-6296
Practice Address - Country:US
Practice Address - Phone:415-294-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1006103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical